Management of Large Breast Hematoma in Patient on Eliquis
Critical Initial Consideration: Mechanical Valve Contraindication
Eliquis (apixaban) is absolutely contraindicated in patients with mechanical heart valves and should never have been prescribed for this indication. 1 The FDA issued a specific contraindication for direct oral anticoagulants in patients with mechanical prosthetic heart valves after the RE-ALIGN trial demonstrated excessive thrombotic complications, including a 5% stroke rate compared to 0% with warfarin, and increased bleeding events 1. If this patient truly has a mechanical valve replacement, she requires immediate transition to warfarin with therapeutic INR monitoring, not continuation of apixaban 1.
If Bioprosthetic Valve (Not Mechanical)
Immediate Hematoma Management
Do not stop Eliquis immediately for this soft tissue hematoma. The breast hematoma, while large at 12cm, represents a non-life-threatening, compressible bleeding site that can be managed conservatively without anticoagulation interruption in most cases 1.
Conservative Management Approach:
- Apply local compression, ice, and supportive measures to the breast hematoma 1
- Monitor hemoglobin levels to assess for ongoing bleeding requiring intervention 2
- Assess hemodynamic stability - blood pressure, heart rate, and signs of hypovolemia 2
- Evaluate hematoma expansion through serial physical examinations over 24-48 hours 1
When to Hold Apixaban
Hold apixaban only if:
- Hemodynamic instability develops (hypotension, tachycardia) 2
- Hemoglobin drops significantly (>2 g/dL) indicating active hemorrhage 2
- Surgical evacuation becomes necessary 1
- Patient develops compartment syndrome or skin necrosis requiring urgent intervention 1
Reversal Considerations
If life-threatening bleeding develops requiring urgent reversal:
- Andexanet alfa is the preferred reversal agent for apixaban, achieving 93% reduction in anti-Xa activity within minutes 1
- Andexanet demonstrated 67% excellent/good hemostatic efficacy in major bleeding events 1
- Prothrombin complex concentrates (PCCs) are an alternative if andexanet unavailable, though less specific 1
Resumption Strategy
If apixaban is held:
- Resume as soon as adequate hemostasis is established without waiting for a specific time interval 3
- For bioprosthetic valves with atrial fibrillation, the stroke risk from withholding anticoagulation exceeds bleeding risk after initial stabilization 1
- Do not wait weeks to restart - the optimal timing for resumption after non-intracranial hemorrhage is measured in days, not weeks 1
Stroke Risk Assessment During Holding Period
The thromboembolic risk during brief anticoagulation interruption is substantial:
- Patients with atrial fibrillation and bioprosthetic valves require continuous anticoagulation 1
- Even short interruptions (48-72 hours) carry stroke risk, particularly in high CHA₂DS₂-VASc scores 3
- Bridge therapy is generally not recommended for brief interruptions in this setting 1
Long-Term Anticoagulation Strategy
For bioprosthetic valve with atrial fibrillation:
- Apixaban is appropriate and supported by ARISTOTLE trial data showing safety and efficacy comparable to warfarin in patients with bioprosthetic valves 4, 5
- Standard apixaban dosing is 5 mg twice daily (or 2.5 mg twice daily if ≥2 of: age ≥80, weight ≤60kg, creatinine ≥1.5 mg/dL) 1
- Avoid adding antiplatelet therapy unless specific coronary indication, as this increases bleeding risk without reducing stroke 6
Critical Action Items
- Verify valve type immediately - mechanical vs bioprosthetic determines entire management strategy 1
- Check hemoglobin and coagulation studies to quantify bleeding severity 2
- Apply local compression and supportive care as first-line management 1
- Continue apixaban unless hemodynamic compromise or expanding hematoma 1
- If mechanical valve confirmed, transition to warfarin urgently with heparin bridge 1