What is the initial ER treatment for a patient with a history of apixaban (generic name: apixaban) for severe non-ischemic cardiomyopathy (NICM) and atrial fibrillation (AFib) presenting with an upper gastrointestinal bleed (UGIB)?

Initial Management of Upper Gastrointestinal Bleeding in a Patient on Apixaban for NICM and Atrial Fibrillation

For a patient with upper gastrointestinal bleeding (UGIB) on apixaban for severe non-ischemic cardiomyopathy (NICM) and atrial fibrillation, immediate resuscitation with fluid support and blood transfusion targeting a hemoglobin of 70-100 g/L should be initiated, followed by early endoscopy within 24 hours of presentation. 1

Initial Resuscitation and Assessment

• Aggressive volume resuscitation and maintenance of hemodynamic stability are the first priorities in patients presenting with substantial UGIB 1
• For hemodynamically unstable patients, initiate fluid resuscitation immediately 1
• Blood transfusion should be given with a target hemoglobin of 70-100 g/L (consider higher threshold of 80 g/L in patients with cardiovascular disease like NICM) 1
• Risk stratification using the Glasgow Blatchford score can help identify patients at high risk of requiring intervention 1
• Nasogastric tube placement may be considered in selected patients as findings have prognostic value 1

Management of Anticoagulation

• Do not delay endoscopy due to the patient being on apixaban 1
• For life-threatening hemorrhage in a patient on apixaban, consider reversal agents:
  • Andexanet alfa is the specific reversal agent for apixaban and should be used for emergency procedures where bleeding risk is significant 1
  • Prothrombin complex concentrates (PCCs) may be considered, though they have not been evaluated in clinical studies 2
  • Note that monitoring for anticoagulation effect using PT, INR, aPTT, or anti-factor Xa activity is not useful when PCCs are used 2

Pharmacological Therapy

• Administer high-dose proton pump inhibitors (PPIs) after resuscitation is initiated 1, 3
• Consider erythromycin as a prokinetic agent to improve visualization during endoscopy 3
• Tranexamic acid may be considered as an adjunctive therapy in severe bleeding, particularly when standard treatments are limited 4

Endoscopic Management

• Perform endoscopy within 24 hours of presentation, with earlier endoscopy (after resuscitation) for high-risk patients with hemodynamic instability 1, 3
• Endoscopic therapy is indicated for high-risk stigmata (active bleeding or visible vessel) 1
• After endoscopic therapy for ulcer bleeding, continue high-dose PPIs 3

Imaging Considerations

• If endoscopy cannot be performed due to massive bleeding or clinical instability, CT angiography (CTA) should be considered to localize the bleeding source 1
• Visceral angiography can be helpful on an emergent basis for overt large bleeding in unstable patients, especially when the bleeding source is unclear 1
• Angiography allows simultaneous treatment by embolization if a bleeding source is identified 1

Resumption of Anticoagulation

• For patients with atrial fibrillation following UGIB, apixaban is optimally restarted approximately one month (32 days) following hemostasis 5
• The timing may be adjusted based on the patient's thromboembolic risk (CHA₂DS₂-VASc score) and rebleeding risk 5

Common Pitfalls to Avoid

• Do not delay endoscopy in patients on anticoagulants as this can lead to worse outcomes 1
• Do not use prothrombin complex concentrates routinely in patients taking direct oral anticoagulants (DOACs) like apixaban prior to emergency procedures 1
• Avoid targeting excessively high hemoglobin levels (>100 g/L) through transfusion as this may increase rebleeding risk 1
• Remember that a negative nasogastric aspirate does not rule out UGIB (3-16% of patients with UGIB may have a negative aspirate) 1

By following this structured approach, patients with UGIB who are on apixaban for NICM and atrial fibrillation can receive optimal care that balances the risks of continued bleeding against the risks of thromboembolism from their underlying cardiac conditions.