Can an 82-year-old male with a history of nonobstructive Coronary Artery Disease (CAD), Heart Failure with reduced Ejection Fraction (HFrEF) of 50%, and atrial fibrillation (afib) on apixaban (apixaban) be off apixaban 2 days before and 1-2 days after a root canal with a bone graft?

Management of Apixaban Interruption for Root Canal with Bone Graft

For an 82-year-old male with nonobstructive CAD, HFrEF 50%, and atrial fibrillation on apixaban, discontinuing apixaban 2 days before and resuming 1-2 days after a root canal with bone graft is appropriate and aligns with current guidelines.

Risk Assessment

Patient-Specific Risk Factors:

• Advanced age (82 years)
• Atrial fibrillation (requiring anticoagulation)
• Nonobstructive coronary artery disease
• Heart failure with reduced ejection fraction (50%)

Procedure Risk Assessment:

• Root canal with bone graft is considered a procedure with moderate bleeding risk
• Dental procedures with bone grafts involve manipulation of tissues that can lead to bleeding

Apixaban Interruption Protocol

Pre-Procedure Management:

• Discontinue apixaban 48 hours (2 days) before the procedure 1
  • This timing is appropriate for patients with normal renal function
  • For patients with moderate renal impairment (CrCl 30-50 mL/min), consider extending to 3 days 2
  • For severe renal impairment (CrCl 15-29 mL/min), extend to 4-5 days 3

Post-Procedure Management:

• Resume apixaban 24-48 hours after the procedure if adequate hemostasis is achieved 1, 2
  • For this moderate bleeding risk procedure, waiting 1-2 days as proposed is appropriate
  • Ensure complete hemostasis before restarting anticoagulation

Evidence-Based Rationale

The French Working Group on Perioperative Hemostasis (GIHP) guidelines specifically address the management of direct oral anticoagulants for elective procedures 3. For procedures with moderate bleeding risk, such as dental procedures with bone grafts, a window without anticoagulation is necessary.

The FDA label for apixaban states: "Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding" 1.

No Need for Bridging Therapy

• Bridging with heparin or low molecular weight heparin is not recommended during the perioperative interruption of apixaban 3
• The American College of Chest Physicians recommends against preoperative bridging when interrupting direct oral anticoagulants 2

Important Considerations

Monitoring for Complications:

• Watch for signs of bleeding at the procedure site
• Monitor for signs of thrombotic events (stroke symptoms, chest pain)
• Ensure adequate hemostasis is achieved before restarting anticoagulation

Potential Pitfalls to Avoid:

1. Inadequate interruption time: Insufficient time off apixaban increases bleeding risk
2. Delayed resumption: Extended time without anticoagulation increases thrombotic risk
3. Unnecessary bridging: Adding heparin increases bleeding risk without additional benefit

Special Considerations for Elderly Patients

For patients over 80 years old, careful monitoring is particularly important as they may have:

• Increased bleeding risk
• Potentially reduced renal function affecting drug clearance
• Higher stroke risk when off anticoagulation

Conclusion

The proposed plan to discontinue apixaban 2 days before and resume 1-2 days after the root canal with bone graft is consistent with current guidelines. This approach balances the risk of procedure-related bleeding against the risk of thrombotic events in this patient with atrial fibrillation and cardiac comorbidities.