Is a 3-day Interlaminar Epidural Steroid Injection (ESI) procedure low risk for perioperative cardiac complications in a patient with a history of Paroxysmal Atrial Fibrillation (PAF), Premature Ventricular Contractions (PVC), Hyperlipidemia (HLD), and currently on Eliquis (Apixaban) anticoagulation therapy?

Perioperative Cardiac Risk Assessment for Interlaminar ESI

Yes, a 3-day hold of Eliquis for interlaminar epidural steroid injection is appropriate, and this procedure carries low risk for perioperative cardiac complications in this patient. 1

Procedure Risk Classification

Interlaminar epidural steroid injections are classified as low-risk procedures (cardiac risk <1%), similar to superficial and minimally invasive procedures that rarely cause excess cardiovascular morbidity or mortality. 1 These procedures involve minimal hemodynamic stress, short duration, and negligible fluid shifts—all factors that contribute to their low cardiac risk profile. 1

Patient-Specific Cardiac Risk Assessment

Current Cardiac Status

Your patient demonstrates well-controlled cardiac disease with several favorable features:

• Preserved left ventricular function: EF 60-65% on recent echocardiogram and EF 70% on nuclear imaging, both well above the high-risk threshold of <35%. 1
• Stable rhythm disorder: PAF status post successful ablation (2019) indicates treated arrhythmia without current instability. 1
• Benign ventricular ectopy: Isolated PVCs without hemodynamic compromise do not increase perioperative cardiac risk and require no specific intervention. 1
• No active cardiac conditions: The patient lacks unstable coronary syndromes, decompensated heart failure, high-grade conduction blocks, or severe valvular disease—the conditions that would mandate delay of elective procedures. 1, 2

Risk Stratification Using Validated Tools

Applying the Revised Cardiac Risk Index (RCRI), this patient likely scores 0-1 points (no high-risk surgery, no active ischemic heart disease, no heart failure, no cerebrovascular disease, no insulin-dependent diabetes, no renal dysfunction mentioned), placing them in the low to low-moderate risk category for major adverse cardiac events. 3, 4, 5

Anticoagulation Management

Eliquis (Apixaban) Perioperative Protocol

A 3-day hold of Eliquis before the procedure is appropriate and safe for neuraxial procedures like epidural injections:

• Apixaban has a half-life of approximately 12 hours; a 3-day (72-hour) hold allows for 6 half-lives, ensuring adequate drug clearance before neuraxial needle placement. 4
• The patient's indication (PAF status post ablation in 2019) suggests low to intermediate thromboembolic risk, making a brief interruption safe. 4
• Resume Eliquis 24 hours after the procedure once hemostasis is assured and there is no concern for epidural hematoma. 1, 4

Thromboembolism Risk Consideration

For patients with atrial fibrillation, the annual stroke risk must be considered:

• Low risk (<4%/year): No bridging anticoagulation needed
• Intermediate risk (4-10%/year): Clinical judgment regarding bridging
• High risk (>10%/year): Consider bridging with low-molecular-weight heparin 4

Given successful ablation in 2019 and no mention of additional stroke risk factors, this patient likely falls into the low-risk category, making the 3-day hold without bridging entirely appropriate. 4

Perioperative Cardiac Management Recommendations

No Additional Cardiac Testing Required

Further cardiac evaluation is not indicated because:

• The procedure is low-risk (<1% MACE rate). 1, 5
• The patient has preserved LV function documented within a reasonable timeframe. 1
• There are no new or worsening cardiac symptoms. 2, 5
• Routine preoperative cardiac testing in stable, low-risk patients does not improve outcomes and may lead to unnecessary delays or interventions. 1

Medication Management

• Continue all cardiac medications (including any beta-blockers, statins, or other cardiovascular drugs) through the morning of the procedure with a sip of water. 1, 5
• Do not initiate high-dose beta-blockers perioperatively, as this increases stroke and mortality risk. 5
• If the patient is on a statin, continue it perioperatively as statins reduce postoperative cardiovascular complications. 5

Monitoring Requirements

For this low-risk procedure in a stable cardiac patient:

• Standard ASA monitoring (continuous ECG, pulse oximetry, blood pressure) is sufficient. 3
• Invasive hemodynamic monitoring is not indicated. 1
• Routine postprocedure intensive care unit admission is unnecessary. 1

Common Pitfalls to Avoid

• Do not delay the procedure for unnecessary cardiac testing: In stable patients undergoing low-risk procedures, additional testing does not change management and only delays needed treatment. 1
• Do not hold Eliquis for longer than necessary: Excessive anticoagulation interruption increases thromboembolic risk without additional bleeding protection benefit. 4
• Do not use phrases like "cleared for surgery": Instead, provide specific risk assessment and management recommendations as outlined above. 2
• Do not ignore the mild fixed defects on nuclear imaging: While these indicate prior infarction, they do not represent active ischemia requiring intervention before a low-risk procedure. 1

Summary Statement for Requesting Physician

This patient with stable cardiac disease (PAF s/p ablation, benign PVCs, preserved EF 60-70%, mild valvular disease) is at low risk for perioperative cardiac complications during interlaminar epidural steroid injection. The 3-day hold of Eliquis is appropriate. Proceed with the procedure using standard monitoring, continue all other cardiac medications, and resume Eliquis 24 hours post-procedure. 1, 4