When to Hold Eliquis (Apixaban) Before Right Heart Catheterization
Eliquis (apixaban) should be held for at least 48 hours before a right heart catheterization procedure due to its high bleeding risk classification. 1
Timing of Discontinuation Based on Renal Function
- For patients with normal renal function (CrCl >30 mL/min), discontinue apixaban at least 48 hours before the procedure 1
- For patients with impaired renal function (CrCl 15-29 mL/min), consider extending the discontinuation period to at least 48 hours, with possible consideration for longer periods 1
- For patients with end-stage renal disease on hemodialysis, apixaban has a modest increase in drug exposure (36% higher AUC), but discontinuation for at least 48 hours is still recommended 2
Risk Stratification Considerations
- Right heart catheterization is classified as a high bleeding risk procedure due to the potential for vascular complications and cardiac perforation 1
- The French Working Group on Perioperative Hemostasis (GIHP) guidelines specifically note that procedures with high bleeding risk require discontinuation of direct oral anticoagulants (DOACs) like apixaban for at least 48 hours 1
- For patients with very high thrombotic risk, consultation with a hematologist is recommended to determine if bridging therapy is necessary 1
Special Considerations for Renal Impairment
- Unlike dabigatran, which requires longer discontinuation periods with declining renal function, apixaban has less renal dependence for clearance 1
- However, in patients with severe renal impairment (CrCl 15-29 mL/min), drug accumulation may occur, and a longer discontinuation period may be warranted 1, 2
- For patients on hemodialysis, studies show that hemodialysis removes only about 4% of apixaban, so timing relative to dialysis sessions has minimal impact on drug clearance 3
Resumption of Anticoagulation After Procedure
- For low bleeding risk after the procedure with adequate hemostasis, apixaban can be resumed at least 6 hours after the procedure 1, 4
- For high bleeding risk or concerns about hemostasis, delay resumption for 48-72 hours 1
- Consider prophylactic doses of heparin or LMWH if there is a prolonged delay in resuming full anticoagulation 1, 4
Common Pitfalls to Avoid
- Unnecessary bridging with heparin products is not recommended for most patients on apixaban and may increase bleeding risk 1
- Resuming full-dose anticoagulation too early after the procedure can lead to significant bleeding complications 4
- Failing to adjust discontinuation timing based on renal function can lead to either excessive bleeding risk or unnecessary thrombotic risk 1
- Laboratory monitoring of anti-Xa activity is generally not required but may be considered in patients with severe renal dysfunction or other factors affecting drug clearance 1