When to Stop Apixaban Before PCI
For elective PCI, stop apixaban 24 hours before transradial access or 48 hours before transfemoral access in patients with normal renal function (creatinine clearance ≥30 mL/min). 1
Timing Based on Access Site and Renal Function
Transradial PCI
- 24 hours if creatinine clearance ≥30 mL/min 1
- 36 hours if creatinine clearance 15-29 mL/min 1
- ≥48 hours (guided by agent-specific anti-Xa level) if creatinine clearance <15 mL/min 1
Transfemoral PCI
- 48 hours if creatinine clearance ≥30 mL/min 1
- ≥72 hours (guided by agent-specific anti-Xa level) if creatinine clearance <29 mL/min 1
Emergency PCI Considerations
In ST-elevation myocardial infarction or high-risk non-ST-elevation myocardial infarction requiring emergency PCI, stop apixaban immediately and proceed with PCI without delay. 1 Activated clotting time may not reliably indicate anticoagulation status in patients taking DOACs. 1
FDA-Approved Guidance
The FDA label recommends discontinuing apixaban at least 48 hours prior to elective surgery or invasive procedures with moderate or high risk of bleeding, and at least 24 hours prior to procedures with low bleeding risk. 2 Bridging anticoagulation during the 24-48 hours after stopping apixaban is not generally required. 2
Pharmacokinetic Rationale
This timing allows for approximately 4-5 half-lives of apixaban elimination, resulting in minimal (≤6%) residual anticoagulant effect at the time of surgery. 3 Apixaban has a half-life of 7-8 hours in patients with normal renal function, with approximately 25% renal clearance. 3
Evidence from Clinical Practice
A prospective observational study demonstrated that apixaban discontinuation for at least 48 hours before procedures resulted in clinically insignificant anticoagulation (94% of patients achieved apixaban concentrations ≤30 ng/mL), with minimal bleeding complications. 4
Common Pitfalls to Avoid
- Do not rely on standard coagulation tests (INR, aPTT) to assess residual apixaban effect, as they are insensitive to DOACs. 1 Use DOAC-calibrated anti-factor Xa levels if measurement is needed. 1
- Adjust timing for renal impairment: Patients with reduced creatinine clearance require longer discontinuation periods due to decreased drug clearance. 1
- Consider access site: Transfemoral access requires longer discontinuation (48 hours vs 24 hours for transradial) due to higher bleeding risk. 1
Resumption After PCI
Restart apixaban as soon as adequate hemostasis has been established, typically 6-24 hours after PCI for low bleeding risk or 24-72 hours for higher bleeding risk procedures. 5, 2 Hemoglobin stability and absence of ongoing bleeding should be confirmed before resumption. 5