How should anticoagulation and antiplatelet therapy be managed in a patient with a history of Non-ST-Elevation Myocardial Infarction (NSTEMI), previous Coronary Artery Bypass Grafting (CABG), and severe native Coronary Artery Disease (CAD) on apixaban (apixaban) and clopidogrel (clopidogrel) who requires a lung biopsy with Endobronchial Ultrasound (EBUS)?

Perioperative Management of Anticoagulation and Antiplatelet Therapy for EBUS Lung Biopsy

For this patient requiring EBUS lung biopsy, discontinue apixaban 48 hours before the procedure and hold clopidogrel for 5-7 days prior to the biopsy, then resume both medications once adequate hemostasis is established post-procedure. 1, 2

Risk Assessment and Procedure Classification

EBUS-guided lung biopsy is classified as a moderate-to-high bleeding risk procedure due to the potential for significant pulmonary hemorrhage and the critical location of bleeding. 1 This classification mandates a more conservative approach to periprocedural anticoagulation management compared to low-risk procedures.

The patient's cardiovascular risk profile is substantial given:

• Recent NSTEMI (7 months ago) with occluded saphenous vein grafts
• Severe native coronary artery disease
• History of SVG thrombus requiring anticoagulation
• Patent LIMA to LAD providing some protection against acute ischemic events

However, the 7-month interval since the acute event places this patient beyond the highest-risk period for recurrent thrombotic complications. 3

Apixaban Management

Discontinue apixaban 48 hours prior to the EBUS procedure. 1 The FDA labeling explicitly states that apixaban should be stopped at least 48 hours before elective surgery or invasive procedures with moderate or high risk of unacceptable or clinically significant bleeding. 1

• Do not use bridging anticoagulation during the 48-hour interruption period, as bridging is not generally required per FDA guidance 1
• The 48-hour window allows adequate clearance of apixaban's anticoagulant effect while minimizing thrombotic risk
• Resume apixaban as soon as adequate hemostasis has been established post-procedure 1

Clopidogrel Management

Discontinue clopidogrel 5-7 days before the EBUS procedure. 2, 3 ACC/AHA guidelines consistently recommend this timeframe for elective procedures requiring hemostasis, with 7 days being preferable when feasible. 2

The rationale for this extended discontinuation period:

• Clopidogrel irreversibly inhibits platelet function 2
• Platelet turnover requires 5-7 days for restoration of adequate hemostatic function 2
• The patient is 7 months post-NSTEMI, beyond the critical 12-month period where dual antiplatelet therapy provides maximum benefit 2, 3

Aspirin Consideration

Do not initiate aspirin monotherapy during the periprocedural period. While ACC/AHA guidelines recommend continuing aspirin through most surgical procedures 2, this patient is not currently on aspirin. The bleeding risk of EBUS biopsy combined with ongoing apixaban (until 48 hours pre-procedure) makes aspirin addition unnecessary and potentially harmful.

Post-Procedure Resumption Strategy

Resume both medications as soon as adequate hemostasis is confirmed, typically within 24 hours post-procedure if no bleeding complications occur. 1

Specific resumption protocol:

• Assess for any signs of bleeding complications (hemoptysis, declining hemoglobin, hemodynamic instability)
• If hemostasis is adequate, restart apixaban at the patient's usual dose 1
• Resume clopidogrel 75 mg daily once bleeding risk is deemed acceptable
• The timing of resumption should prioritize thrombotic risk given this patient's history of SVG thrombus and severe CAD

Critical Pitfalls to Avoid

Do not bridge with heparin or low molecular weight heparin during the apixaban interruption period. 1 The FDA labeling explicitly states bridging is not generally required, and adding parenteral anticoagulation would increase bleeding risk without proven benefit in this timeframe.

Do not perform the procedure if clopidogrel has been held for less than 5 days unless the clinical urgency outweighs bleeding risk. 2 While more urgent procedures can be performed by experienced operators if bleeding risk is acceptable, EBUS for lung biopsy is typically an elective diagnostic procedure that can be appropriately timed. 2

Do not restart anticoagulation or antiplatelet therapy prematurely. Ensure adequate hemostasis is established, as pulmonary hemorrhage post-EBUS can be life-threatening and difficult to control. 1

Long-Term Antithrombotic Strategy

After the procedure, continue the patient's baseline regimen of apixaban plus clopidogrel indefinitely given:

• History of SVG thrombus requiring anticoagulation
• Severe native CAD with prior NSTEMI
• Occluded bypass grafts with patent LIMA providing limited revascularization 3, 4

This dual therapy approach (anticoagulant plus single antiplatelet agent) is supported for patients with both an anticoagulation indication and coronary artery disease, though it does carry increased bleeding risk compared to monotherapy. 4, 5