Apixaban (Eliquis) Washout Period Before Heart Catheterization
For heart catheterization, apixaban should be discontinued at least 24 hours prior to the procedure if using a radial approach (low bleeding risk) and at least 48 hours prior if using a femoral approach (higher bleeding risk), with adjustments based on renal function. 1, 2
Recommended Washout Period Based on Procedure Risk and Approach
Radial Approach (Low Bleeding Risk)
- Hold apixaban for at least 24 hours if creatinine clearance (CrCl) ≥30 mL/min 2
- Hold apixaban for at least 36 hours if CrCl 15-29 mL/min 2
- For patients with CrCl <15 mL/min, consider holding for at least 48 hours or guide duration by anti-Xa level 2
Femoral Approach (Higher Bleeding Risk)
- Hold apixaban for at least 48 hours if CrCl ≥30 mL/min 2, 1
- Hold apixaban for at least 72 hours if CrCl <30 mL/min 2
Factors Affecting Washout Decisions
Renal Function Considerations
- Apixaban has approximately 27% renal clearance, less than other DOACs 3
- Patients with impaired renal function (CrCl <30 mL/min) require longer washout periods 2
- For patients with normal renal function, apixaban discontinuation for at least 48 hours before a procedure results in clinically insignificant anticoagulation levels 4
Thrombotic Risk Assessment
- For patients at high thrombotic risk (CHA₂DS₂-VASc score ≥2), the shortest appropriate washout period should be used 2
- No bridging with LMWH/UFH is generally required during the washout period 2
- The rapid onset of action of apixaban obviates the need for heparin bridging 2
Resumption of Apixaban After Procedure
- Resume full dose of apixaban ≥24 hours after low bleeding risk procedures 2
- Resume full dose of apixaban 48-72 hours after high bleeding risk procedures 2
- Restart only after adequate hemostasis has been established 1
- For heart catheterization specifically, apixaban can typically be resumed 6 hours or more after the end of the procedure if hemostasis is adequate 2
Special Considerations
Urgent/Emergent Procedures
- In emergency situations (e.g., STEMI), proceed with catheterization without delay regardless of apixaban status 2
- For urgent but non-emergency cases, consider measuring anti-Xa activity if available to assess residual anticoagulant effect 2
Bleeding Risk Management
- Radial approach for cardiac catheterization may be preferred in patients with recent apixaban use, as it has lower bleeding risk 5
- Studies have shown that some procedures can be safely performed without interruption of anticoagulation when using radial approach 6
- The ADIOS study demonstrated that apixaban discontinuation for at least 48 hours resulted in minimal residual anticoagulant effect (apixaban concentration ≤30 ng/mL in 94% of patients) 4
Common Pitfalls to Avoid
- Unnecessarily long washout periods increase thrombotic risk 2
- Inadequate washout increases bleeding risk, especially with femoral approach 2
- Failure to adjust washout period based on renal function 2
- Automatic bridging with heparin is not recommended and may increase bleeding risk without reducing thrombotic events 2
Remember to provide the patient with written instructions indicating the date and time of their procedure and the exact timing of their last apixaban dose 2.