Can a patient with a history of ovarian cancer, atrial fibrillation (AF), provoked pulmonary embolism (PE), and hypertension (HTN), on apixaban (eliquis), with a CHA2DS2-VASc score of 6, restart apixaban 2 weeks post small right subdural hemorrhage?

Restarting Apixaban After Subdural Hemorrhage in a Patient with High Thromboembolic Risk

For a patient with a CHA2DS2-VASc score of 6 and a small right subdural hemorrhage 2 weeks ago, apixaban should be restarted at 4 weeks after the bleeding event, as this timing provides the optimal balance between thromboembolic and rebleeding risks.

Understanding CHA2DS2-VASc Score of 6

A CHA2DS2-VASc score of 6 indicates:

• Very high risk of stroke (9.8% annual adjusted stroke rate) 1
• This patient falls into a high thrombotic risk category due to multiple comorbidities (atrial fibrillation, hypertension, history of provoked pulmonary embolism, and likely age >75 years)
• Without anticoagulation, this patient faces significant risk of thromboembolic events

Management Algorithm for Restarting Anticoagulation

Step 1: Assess Thromboembolic Risk

• CHA2DS2-VASc score of 6 places this patient in a high-risk category for stroke
• History of provoked PE further increases thromboembolic risk
• Ovarian cancer history adds to thrombotic risk (cancer is prothrombotic)

Step 2: Assess Bleeding Risk

• Small right subdural hemorrhage 2 weeks ago (critical site bleeding)
• Subdural hemorrhage is considered a critical site bleeding according to guidelines 1
• Current timing (2 weeks post-bleed) is too early for safe resumption

Step 3: Determine Optimal Timing for Anticoagulation Restart

• According to the 2020 ACC Expert Consensus, anticoagulation should be delayed when bleeding occurred at a critical site 1
• For traumatic subdural hematomas, anticoagulation should be restarted approximately 4 weeks after surgical removal or stabilization 2
• Apixaban should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established 3

Recommended Approach

1. Wait until 4 weeks post-bleeding event before restarting apixaban 1, 2
2. Consider brain imaging (CT/MRI) before reinitiating anticoagulation to confirm stability of the subdural hematoma 1
3. Resume standard dose apixaban (5mg twice daily) if renal function is normal, or reduced dose (2.5mg twice daily) if the patient meets dose reduction criteria 3

Important Considerations

• High thromboembolic risk: With a CHA2DS2-VASc score of 6, this patient has approximately 9.8% annual risk of stroke without anticoagulation 1
• Bridging therapy: If thromboembolic risk is deemed extremely high during the waiting period, consider prophylactic doses of parenteral anticoagulants with close monitoring 1
• Close monitoring: After restarting apixaban, monitor closely for signs of recurrent bleeding for the first 2-4 weeks 2
• Patient education: Advise the patient about warning signs requiring immediate medical attention (new-onset severe headache, confusion, decreased consciousness) 2

Cautions and Pitfalls

• Avoid restarting too early: Restarting anticoagulation too early (at 2 weeks) increases risk of recurrent intracranial hemorrhage
• Avoid prolonged interruption: Delaying anticoagulation beyond 4 weeks unnecessarily increases thromboembolic risk
• Avoid bridging with full-dose anticoagulation: If bridging is needed, use prophylactic rather than therapeutic doses
• Consider reduced dose initially: When restarting, some experts suggest beginning with a reduced dose for the first few days, though this is not in official guidelines

The 4-week waiting period represents the optimal balance between preventing thromboembolic events while minimizing rebleeding risk for this high-risk patient with a recent subdural hemorrhage.