Is Eliquis (apixaban) appropriate for use in patients undergoing Transcatheter Aortic Valve Replacement (TAVR)?

Apixaban (Eliquis) Use in Patients Undergoing TAVR

For patients with atrial fibrillation undergoing TAVR, apixaban (Eliquis) is appropriate and should be used as the anticoagulant of choice, but for patients without an indication for anticoagulation, apixaban may increase mortality compared to standard antiplatelet therapy and is not recommended. 1

Antithrombotic Therapy After TAVR

Patients WITHOUT Indications for Anticoagulation

• Standard antithrombotic therapy after TAVR is clopidogrel 75 mg daily for 3-6 months plus aspirin 75-100 mg daily lifelong 2
• NOACs including apixaban may increase all-cause mortality when compared to antiplatelet therapy in patients without an indication for anticoagulation 1
• Recent evidence suggests that apixaban may increase mortality (RR 1.71,95% CI 0.97 to 3.02) compared to antiplatelet therapy in patients without an indication for anticoagulation 1
• Dual antiplatelet therapy has been associated with increased bleeding risk compared to single antiplatelet therapy, particularly early after the procedure 3

Patients WITH Indications for Anticoagulation (e.g., Atrial Fibrillation)

• Patients with chronic AF or other indications for long-term anticoagulation should receive anticoagulation as per guidelines for AF in patients with prosthetic heart valves 2
• Apixaban may be as effective as vitamin K antagonists in preventing all-cause mortality, cardiovascular death, and stroke in patients with an indication for anticoagulation after TAVR 1
• Apixaban may lead to a similar rate of major bleeding as vitamin K antagonists in this population (RR 0.90,95% CI 0.53 to 1.54) 1
• When anticoagulation is used, continuation of aspirin is reasonable, but it may be prudent to avoid other antiplatelet therapy in some patients given the increased risk of bleeding with multiple antithrombotic agents 2

Clinical Considerations for Anticoagulation After TAVR

Valve Thrombosis Prevention

• Subclinical leaflet thrombosis can occur after TAVR and is less prevalent in patients on anticoagulation 4
• Apixaban has been shown to reduce subclinical obstructive valve thrombosis compared to antiplatelet therapy (OR: 0.51; 95% CI: 0.30-0.86) but not compared to vitamin K antagonists 5
• Despite this benefit, routine anticoagulation after TAVR in high-surgical-risk patients without an indication for anticoagulation has been associated with increased mortality and thromboembolic complications 4

Monitoring and Follow-up

• Echocardiography before discharge provides a new baseline of transcatheter valve function 2
• Repeat echocardiography is recommended at 30 days and then at least annually to monitor for complications of TAVR 2
• Periodic ECG monitoring is recommended for detection of asymptomatic AF, as pre-existing AF is present in about 25% of patients who undergo TAVR, and new-onset AF after TAVR ranges from <1% to 8.6% 2

Practical Approach to Anticoagulation in TAVR Patients

Algorithm for Antithrombotic Therapy After TAVR:

1. For patients WITH atrial fibrillation or other indications for anticoagulation:

   • Use apixaban at appropriate dosing (typically 5mg twice daily, with dose reduction to 2.5mg twice daily for patients meeting criteria) 6, 5
   • Consider adding low-dose aspirin (75-100mg daily) 2
   • Avoid triple therapy with dual antiplatelet therapy plus anticoagulation due to excessive bleeding risk 3

2. For patients WITHOUT indications for anticoagulation:

   • Use clopidogrel 75mg daily for 3-6 months plus aspirin 75-100mg daily lifelong 2
   • Do not initiate apixaban or other anticoagulants solely for the prevention of subclinical leaflet thrombosis 4

Special Considerations

• If clinical valve thrombosis develops, anticoagulation should be initiated regardless of baseline indication 4
• In patients with high bleeding risk, consider single antiplatelet therapy rather than dual antiplatelet therapy if no indication for anticoagulation exists 3
• Careful monitoring for bleeding complications is essential, especially in elderly TAVR patients who often have multiple comorbidities 2

By following these evidence-based recommendations, clinicians can optimize antithrombotic therapy after TAVR to reduce the risk of both thrombotic and bleeding complications while improving patient outcomes.