How should a patient with atrial fibrillation (AFib), ventricular tachycardia (VTE), heart failure with reduced ejection fraction, and a biventricular pacemaker, who has been off Eliquis (apixaban) since Sunday, be bridged until cardiac catheterization tomorrow?

Bridging Anticoagulation for Cardiac Catheterization

This patient should NOT receive bridging anticoagulation with heparin or LMWH before cardiac catheterization tomorrow. Instead, proceed directly with the catheterization while off Eliquis, and resume anticoagulation post-procedure once hemostasis is achieved.

Why Bridging is NOT Indicated

Bridging anticoagulation in patients with nonvalvular atrial fibrillation increases bleeding risk 2-3 fold without reducing stroke risk, making it inappropriate for the vast majority of AF patients. 1

• Your patient has been off Eliquis since Sunday (4 days), which is adequate clearance for a procedure scheduled tomorrow (Friday) 2
• The FDA label for apixaban explicitly states: "Bridging anticoagulation during the 24 to 48 hours after stopping apixaban tablets and prior to the intervention is not generally required" 2
• Current ACC/AHA guidelines recommend that bridging decisions should balance stroke and bleeding risks against the duration without anticoagulation, and for patients without mechanical heart valves, bridging is rarely indicated 3

Risk Stratification for This Patient

This patient does NOT meet criteria for bridging therapy:

• No mechanical heart valve - the only absolute indication for bridging 3, 1
• No recent stroke/TIA within 3 months 4
• While he has multiple comorbidities (AFib, VT, HFrEF with EF 30-40%, biventricular pacemaker), these do NOT constitute indications for bridging 1, 4
• The landmark BRIDGE trial demonstrated that absence of bridging was noninferior to bridging with LMWH for preventing arterial thromboembolism and significantly decreased bleeding risk 1

Procedural Management Plan

For cardiac catheterization tomorrow:

• Proceed with catheterization - 4 days off apixaban provides adequate clearance (apixaban should be stopped 48 hours prior for transfemoral access procedures) 3
• No bridging anticoagulation needed - do not start heparin or LMWH 1, 2
• Resume Eliquis 5 mg twice daily within 24 hours post-procedure once adequate hemostasis is established 2
• Consider radial access if feasible, as it reduces bleeding complications 3

Post-Procedure Anticoagulation

Resume full-dose anticoagulation promptly:

• Restart Eliquis 5 mg twice daily as soon as hemostasis is secured, typically within 24 hours post-catheterization 2
• No dose adjustment needed unless combined P-gp and strong CYP3A4 inhibitors are being used 2
• Continue indefinitely given his AFib and stroke risk factors 3

Critical Pitfalls to Avoid

The most common error is unnecessary bridging in average-risk AF patients - this increases major hemorrhage rates from 0.5% to 2.7% without reducing thromboembolism 1

• German registry data showed bridging resulted in 5-fold higher bleeding (2.7% vs 0.5%, p=0.01) with no reduction in stroke 1
• The RE-LY trial demonstrated bridging resulted in higher major hemorrhage (6.5% vs 1.8%, p<0.001) with no difference in thrombosis rates 1
• Do NOT combine anticoagulation with dual antiplatelet therapy unless absolutely necessary for recent PCI, as this increases bleeding risk by >50% 1

Special Considerations for Heart Failure

This patient's HFrEF (EF 30-40%) does not change anticoagulation management:

• Oral anticoagulation is recommended for all patients with AF and HF, independent of HF type 5
• His current regimen of Eliquis 5 mg twice daily is appropriate - no dose reduction needed based on his age (64 years), and assuming weight >60 kg and creatinine <1.5 mg/dL 2
• Continue Entresto (sacubitril/valsartan) and sotalol as scheduled 6