Can I continue Eliquis (apixaban) for a patient with severe aortic stenosis, coronary artery disease (CAD) and congestive heart failure (CHF) with anemia (Hgb 8.8)?

Management of Apixaban in a Patient with Severe Aortic Stenosis, CAD, CHF, and Anemia

In a patient with severe aortic stenosis, CAD, CHF, and anemia with Hgb 8.8, apixaban should be temporarily discontinued until the hemoglobin level can be improved to at least >10 g/dL, as the bleeding risk outweighs the thrombotic benefit in this clinical scenario.

Assessment of Bleeding Risk vs. Thrombotic Risk

Factors Increasing Bleeding Risk:

• Current anemia (Hgb 8.8): Significant anemia increases bleeding risk and may indicate active or recent bleeding
• Severe aortic stenosis: Associated with acquired von Willebrand syndrome and increased bleeding risk
• Heart failure: May require medications that increase bleeding risk (e.g., diuretics affecting renal function)
• Potential need for procedures: Patients with severe aortic stenosis may need intervention requiring anticoagulation interruption

Approach to Management:

1. Evaluate cause of anemia:

   • Assess for active bleeding (GI, genitourinary)
   • Consider iron studies to evaluate for iron deficiency
   • Evaluate renal function (may affect both anemia and apixaban dosing)

2. Blood transfusion considerations:

   • Follow restrictive transfusion strategy (Hgb threshold 7-8 g/dL) as recommended by ACP guidelines 1
   • Consider transfusion if patient is symptomatic from anemia or has active cardiac ischemia

3. Iron supplementation:

   • Consider IV iron if iron deficiency is confirmed
   • IV iron has shown benefits in heart failure patients with or without anemia 1

4. Anticoagulation management:

   • Temporarily hold apixaban until hemoglobin improves to >10 g/dL
   • Consider bridging with lower doses or alternative anticoagulation if thrombotic risk is very high
   • Resume apixaban once hemoglobin is stable and >10 g/dL with close monitoring

Special Considerations in Cardiac Disease

Aortic Stenosis:

• Severe aortic stenosis increases bleeding risk due to acquired von Willebrand syndrome
• Patients with severe aortic stenosis may need valve intervention (SAVR or TAVR) which would require anticoagulation management 1
• If valve intervention is planned, coordinate anticoagulation interruption with the heart team

Coronary Artery Disease:

• CAD with severe aortic stenosis may require revascularization strategy 2, 3
• If coronary intervention is needed, anticoagulation management becomes more complex
• Consider cardiology consultation to determine optimal revascularization strategy and timing

Heart Failure:

• Heart failure with anemia is associated with worse outcomes
• Anemia may exacerbate heart failure symptoms
• Prioritize heart failure optimization alongside anemia management

Monitoring and Follow-up

1. Short-term monitoring:

   • Weekly CBC to track hemoglobin response
   • Monitor for signs of thrombosis during apixaban interruption
   • Assess cardiac symptoms (angina, dyspnea) that may worsen with anemia

2. Long-term considerations:

   • Once hemoglobin improves to >10 g/dL, reassess risk-benefit of continuing apixaban
   • Consider lower dose of apixaban if renal function is impaired
   • Regular monitoring of hemoglobin and renal function

Pitfalls and Caveats

• Don't continue full-dose anticoagulation with active bleeding or severe unexplained anemia
• Don't transfuse to normal hemoglobin levels as liberal transfusion strategies have not shown benefit in cardiac disease 1
• Don't use erythropoiesis-stimulating agents as they increase thrombotic risk without clear benefit in cardiac patients 1
• Don't forget to investigate the cause of anemia rather than simply treating the low hemoglobin
• Don't permanently discontinue anticoagulation without reassessing thrombotic risk once anemia resolves

This approach balances the immediate bleeding risk against the long-term thrombotic risk, with a plan to resume appropriate anticoagulation once the anemia has been adequately addressed.