Apixaban Discontinuation Before Cardiac Ablation
For patients taking apixaban 5 mg BID, discontinuation should occur 24 hours before cardiac ablation for low bleeding risk procedures and 48 hours before for high bleeding risk procedures. 1
Timing of Apixaban Discontinuation Based on Bleeding Risk
The 2023 ACC/AHA/ACCP/HRS guideline provides specific recommendations for discontinuing apixaban before invasive procedures:
| Bleeding Risk | Timing of Last Apixaban Dose |
|---|---|
| Low bleeding risk | 1 day before procedure |
| High bleeding risk | 2 days before procedure |
These recommendations apply to patients with creatinine clearance >25 mL/min. For patients with lower creatinine clearance, consider holding for an additional 1-3 days, especially for high bleeding risk procedures 1.
Cardiac Ablation-Specific Considerations
Cardiac ablation procedures can be classified based on bleeding risk:
- Low bleeding risk ablations: Simple ablations with limited tissue damage
- High bleeding risk ablations: Complex ablations with extensive tissue manipulation or those requiring transseptal puncture
The FDA label for apixaban states that it should be discontinued at least 24 hours prior to procedures with low bleeding risk and at least 48 hours prior to procedures with moderate or high bleeding risk 2.
Restarting Apixaban After Ablation
Apixaban should be restarted after the procedure as soon as adequate hemostasis has been established 2. The European Heart Rhythm Association recommends:
- For low bleeding risk procedures: Resume full dose of apixaban ≥24 hours post-procedure
- For high bleeding risk procedures: Resume full dose of apixaban 48-72 hours post-procedure 1
Special Considerations
Renal Function Impact
For patients with impaired renal function, longer discontinuation periods may be necessary:
- Standard timing applies for CrCl >25 mL/min
- Consider additional 1-3 days for CrCl <25 mL/min 1
Uninterrupted Apixaban Strategy
Some evidence suggests that uninterrupted apixaban therapy during AF ablation may be safe. A meta-analysis showed similar rates of thromboembolic complications (0.68% vs 0.66%) and major bleeding (0.85% vs 0.77%) between uninterrupted apixaban and vitamin K antagonists 3. However, the 2023 ACC/AHA/ACCP/HRS guideline still recommends temporary discontinuation based on bleeding risk 1.
Important Caveats
- No bridging necessary: Unlike warfarin, bridging anticoagulation during the 24-48 hours after stopping apixaban is not generally required 2
- Timing calculation: The number of days indicated is the number of full days before surgery during which no dose is taken. The drug is also not taken on the day of surgery 1
- Documentation: Patients should receive written instructions indicating the date and time of their procedure and the date and time of the last intake of apixaban 1
- Monitoring: Careful post-procedure monitoring is essential to detect any bleeding complications early
By following these evidence-based recommendations for apixaban discontinuation before cardiac ablation, clinicians can minimize both thromboembolic and bleeding risks in patients with atrial fibrillation.