How should anemia be managed in an 87-year-old patient with severe aortic stenosis, on Eliquis (apixaban), with hypertension and congestive heart failure?

Management of Anemia in an 87-Year-Old Patient with Severe Aortic Stenosis, Hypertension, and CHF on Eliquis

For an 87-year-old patient with severe aortic stenosis, CHF, hypertension, and a hemoglobin of 8.8 g/dL on Eliquis 2.5 mg, a restrictive red blood cell transfusion strategy should be implemented with a hemoglobin threshold of 7-8 g/dL, while investigating and treating the underlying cause of anemia.

Evaluation of Anemia

First, determine the type and cause of anemia:

• Obtain complete blood count with MCV and RDW to classify anemia as microcytic, normocytic, or macrocytic 1
• Check iron studies including serum ferritin and transferrin saturation 1
• Consider vitamin B12 and folate levels, especially if macrocytic 1
• Evaluate for occult blood loss, particularly given the patient is on Eliquis (apixaban)

Transfusion Considerations

The American College of Physicians recommends:

• Use a restrictive red blood cell transfusion strategy with a hemoglobin threshold of 7-8 g/dL in patients with coronary heart disease 2
• This patient's current hemoglobin of 8.8 g/dL is above the recommended transfusion threshold 2
• Transfusion should be reserved primarily for patients with severe anemia symptoms who need rapid hemoglobin improvement 2

Treatment Approach

1. Iron supplementation:

   • If iron deficiency is confirmed (ferritin <15 μg/L or 15-45 μg/L with low transferrin saturation), initiate iron replacement 1
   • Consider intravenous iron if oral iron is not tolerated or in cases of severe anemia (Hb <10 g/dL) 1

2. Avoid erythropoiesis-stimulating agents:

   • The ACP strongly recommends against using ESAs in patients with mild to moderate anemia and CHF or coronary heart disease 2

3. Monitor cardiac function:

   • Anemia can worsen cardiac function and is associated with increased risk for hospitalization, death, decreased exercise capacity, and poor quality of life in heart failure patients 2
   • Patients with severe aortic stenosis and anemia have increased all-cause mortality while under medical therapy 3

4. Consider anticoagulation management:

   • The patient is on a reduced dose of Eliquis (2.5 mg), which is appropriate for elderly patients
   • Monitor for signs of bleeding given the increased risk with anticoagulation in anemic patients

Special Considerations for Aortic Stenosis

• Anemia prevalence increases with severity of aortic stenosis (35.6% in severe AS) 3
• Each 1.0 g/dL decrease in hemoglobin is independently associated with increased mortality risk in severe AS patients 3
• After aortic valve replacement, anemic patients have similar survival rates as patients with normal hemoglobin levels 3
• Elderly patients with severe AS often have pulmonary hypertension due to left heart congestion 4, which can be exacerbated by anemia

Follow-up and Monitoring

• Repeat complete blood count after 4 weeks to evaluate response to therapy 1
• Continue iron therapy for 2-3 months after normalization of hemoglobin to replenish iron stores 1
• Monitor for signs of heart failure exacerbation, as anemia can worsen cardiac function 2

Pitfalls to Avoid

1. Don't transfuse based solely on hemoglobin numbers without considering symptoms and overall clinical picture
2. Don't use erythropoiesis-stimulating agents as they increase risks without clear benefits in CHF patients 2
3. Don't miss underlying gastrointestinal malignancy in elderly patients with iron deficiency anemia - endoscopy may be warranted 5
4. Don't overlook the potential for occult bleeding with Eliquis, even at reduced doses

This approach balances the risks of anemia against the risks of transfusion in an elderly patient with significant cardiovascular comorbidities, while addressing the underlying cause of anemia to improve long-term outcomes.