What is the evidence for using apixaban (Eliquis) in patients with heart failure (HF) and a history of provoked venous thromboembolism (VTE)?

Apixaban for Heart Failure Patients with History of Provoked VTE

For patients with heart failure and a history of provoked VTE, extended anticoagulation with apixaban is not recommended as there is no evidence supporting this practice and it would incur unnecessary costs and bleeding risks.

Evidence-Based Recommendations for VTE Treatment in Heart Failure

• For patients with VTE diagnosed in the setting of a major transient risk factor, extended-phase anticoagulation is strongly recommended against 1
• For patients with VTE diagnosed in the setting of a minor transient risk factor, extended-phase anticoagulation is suggested against 1
• The standard recommendation for provoked VTE is a 3-month treatment phase of anticoagulation, after which therapy should be discontinued 1

Heart Failure as a Risk Factor

• Heart failure alone is not considered an indication for extended anticoagulation after completing standard treatment for a provoked VTE 1
• Despite recommendations that hospitalized NYHA class III and IV heart failure patients receive VTE prophylaxis during hospitalization, this is different from extended treatment after a VTE event 2

Cost Considerations

• Extended anticoagulation with medications like apixaban represents a significant cost (approximately $600/year as mentioned in your question)
• This cost is not justified for patients with provoked VTE who have completed their standard 3-month treatment course, even with concurrent heart failure 1

Risk-Benefit Analysis

• The risk of recurrent VTE after completing standard therapy for a provoked event is low, even in patients with heart failure 1
• Continuing anticoagulation beyond the recommended treatment period exposes patients to:
  • Increased bleeding risk 1
  • Medication costs 1
  • Monitoring burden 1

When Extended Anticoagulation IS Recommended

• Extended anticoagulation is recommended for unprovoked VTE or VTE provoked by persistent risk factors 1
• In these cases, reduced-dose apixaban (2.5mg twice daily) is suggested over full-dose apixaban 1
• Heart failure alone does not qualify as a persistent risk factor requiring extended anticoagulation after a provoked VTE 1

Recent Evidence

• The 2021 CHEST guidelines make a strong recommendation against extended anticoagulation for VTE associated with major transient risk factors 1
• These guidelines place "a very high value on avoiding the potential increase in harm when the magnitude of benefit is variable" 1

Conclusion

For a patient with heart failure and a history of provoked VTE who has completed the standard 3-month treatment course, extended anticoagulation with apixaban is not supported by current evidence and guidelines. The additional cost and bleeding risk outweigh any potential benefit in this specific patient population.