When to start Eliquis (apixaban) after Left Heart Catheterization (LHC) with no intervention?

From the Guidelines

Eliquis (apixaban) should be restarted 24 hours after a left heart catheterization (LHC) with no intervention, assuming adequate hemostasis at the access site has been achieved and creatinine clearance is ≥30 ml/min, as recommended by the 2021 ACC expert consensus decision pathway 1. When considering the timing of restarting Eliquis after LHC, it's essential to balance the risk of thrombotic events with the risk of bleeding complications. The 2021 ACC expert consensus decision pathway provides guidance on holding direct oral anticoagulants (DOACs) for elective percutaneous coronary intervention (PCI) 1.

• For patients with creatinine clearance ≥30 ml/min, the recommended duration for holding apixaban is 24 hours for transradial PCI and 48 hours for transfemoral PCI.
• The decision to restart Eliquis should be individualized based on the patient's bleeding risk factors, renal function, and the specific procedure performed.
• Ensuring complete hemostasis at the access site is crucial before restarting Eliquis, which typically involves checking for absence of active bleeding, hematoma formation, or vascular complications.
• The pharmacokinetics of apixaban, which reaches peak plasma levels within 3-4 hours of administration, supports the recommended timing for restarting the medication 1. It's also important to note that the 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation suggests that NOAC intake can be resumed 3–5 hours after sheath removal if adequate haemostasis is established and pericardial effusion has been ruled out 1. However, the more recent and higher-quality study from 2021 1 provides more specific guidance on the timing of restarting apixaban after LHC. Always follow the specific instructions from your cardiologist, as they may adjust this recommendation based on your individual clinical situation.

From the FDA Drug Label

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 [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled. Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.

The FDA drug label does not provide a specific recommendation for when to start Eliquis (apixaban) after Left Heart Catheterization (LHC) with no intervention. However, it does provide guidance on when to restart apixaban after surgical or other procedures, which is as soon as adequate hemostasis has been established.

• Key consideration: The decision to start apixaban after LHC should be based on the individual patient's risk of bleeding and thromboembolism.
• Clinical decision: Apixaban can be restarted after LHC with no intervention as soon as adequate hemostasis has been established, but the exact timing is not specified in the label 2.

From the Research

Timing of Eliquis (Apixaban) Initiation after Left Heart Catheterization (LHC)

There are no research papers provided that directly address the timing of Eliquis (apixaban) initiation after Left Heart Catheterization (LHC) with no intervention.

Available Evidence on Apixaban

• The provided studies compare the safety and efficacy of apixaban with warfarin in patients with atrial fibrillation and advanced chronic kidney disease 3, 4, 5, 6, 7.
• These studies suggest that apixaban may be associated with a lower risk of major bleeding and similar or reduced risks of stroke/systemic embolism compared to warfarin in patients with atrial fibrillation and renal impairment 4, 5, 6, 7.
• However, none of the studies provide guidance on the timing of apixaban initiation after LHC with no intervention.

Key Findings

• Apixaban may be a safer alternative to warfarin in patients with atrial fibrillation and renal impairment, with a lower risk of major bleeding 4, 5, 6, 7.
• The studies provided do not address the specific question of when to start Eliquis (apixaban) after LHC with no intervention.

Limitations

• The available evidence does not provide direct guidance on the timing of apixaban initiation after LHC with no intervention.
• Further research is needed to determine the optimal timing of apixaban initiation in this context.