What should a patient with heart failure (HF) who stopped taking his anticoagulant medication, Eliquis (apixaban), for a month do now that he is experiencing chest pain?

Management of Chest Pain in Heart Failure Patient Who Stopped Apixaban

A heart failure patient who stopped taking apixaban (Eliquis) for a month and is now experiencing chest pain should immediately seek emergency medical evaluation to rule out acute coronary syndrome or pulmonary embolism, and should resume anticoagulation therapy as soon as medically cleared. 1, 2

Immediate Evaluation

• Urgent medical assessment is required to determine if chest pain is due to:

  • Acute coronary syndrome (ACS)
  • Pulmonary embolism (PE) due to stopping anticoagulation
  • Heart failure exacerbation
  • Other cardiac or non-cardiac causes

• Initial assessment should include:

  • 12-lead ECG with comparison to previous ECGs
  • Cardiac biomarkers (troponin)
  • Multi-lead ECG ischemia monitoring
  • Assessment of hemodynamic stability 1

Risk Assessment

The patient is at high risk due to:

1. Discontinuation of anticoagulation: Stopping apixaban increases thrombotic risk, particularly in heart failure patients 2
2. Heart failure status: Both prior and acute heart failure are associated with increased risk of subsequent clinical events 3
3. Current chest pain: May indicate ACS, which requires immediate intervention 1

Management Algorithm

Step 1: Emergency Department Management

• Immediate ECG and cardiac biomarkers
• Initiate oxygen if hypoxic
• Administer aspirin 250-500mg if ACS is suspected 1
• Consider nitrates for ongoing chest pain if not contraindicated

Step 2: Based on Initial Assessment

• If ACS is confirmed:

  • Follow ACS protocol with antiplatelet therapy
  • Consider invasive strategy based on risk assessment 1
  • Restart anticoagulation when appropriate based on bleeding risk

• If pulmonary embolism is suspected:

  • Obtain CT pulmonary angiogram
  • Resume therapeutic anticoagulation immediately if confirmed and no contraindications 2

• If symptoms are due to heart failure exacerbation:

  • Optimize guideline-directed medical therapy (GDMT)
  • Resume anticoagulation (apixaban 5mg twice daily unless dose adjustment criteria are met) 2

Step 3: Resuming Anticoagulation

• For most patients: Resume apixaban 5mg twice daily 2
• For patients with ≥2 of the following: Use reduced dose of 2.5mg twice daily
  • Age ≥80 years
  • Body weight ≤60kg
  • Serum creatinine ≥1.5mg/dL 2

Important Considerations

Anticoagulation in Heart Failure

• Heart failure creates a hypercoagulable state with elevated pro-thrombotic and pro-inflammatory cytokines 4
• Apixaban has shown benefit in heart failure patients with atrial fibrillation 3
• Patients with heart failure who stop anticoagulation are at increased risk for thrombotic events 2, 4

Medication Adherence

• Discuss reasons for medication discontinuation
• Emphasize the importance of adherence to GDMT including:
  • Beta-blockers (bisoprolol, carvedilol, or metoprolol succinate)
  • ACE inhibitors or ARBs
  • Diuretics if fluid retention is present 1

Monitoring After Resuming Anticoagulation

• Follow-up within 1 week to assess:
  • Resolution of symptoms
  • Medication adherence
  • Signs of bleeding complications 2

Common Pitfalls to Avoid

1. Delaying evaluation: Chest pain in a heart failure patient who stopped anticoagulation requires immediate medical attention
2. Missing the diagnosis: Consider multiple etiologies including ACS, PE, and heart failure exacerbation
3. Inadequate anticoagulation: Ensure proper dosing when restarting apixaban
4. Failure to address adherence: Identify and address barriers to medication adherence
5. Overlooking drug interactions: Check for medications that may interact with apixaban, particularly combined P-gp and strong CYP3A4 inhibitors 2

Remember that premature discontinuation of anticoagulation therapy significantly increases thrombotic risk, and patients should be educated about the importance of not stopping apixaban without medical consultation 2.