When to restart Eliquis (apixaban) after a myocardial infarction (MI)?

When to Restart Eliquis (Apixaban) After Myocardial Infarction

Critical Context: MI Alone is NOT a High-Risk Indication for Anticoagulation

Anticoagulation after MI without left ventricular thrombus is considered a temporary indication and should generally be discontinued, not restarted. 1 The 2020 ACC Expert Consensus explicitly lists "OAC after an anterior MI without left ventricular thrombus" as a temporary indication where discontinuing anticoagulation is suggested. 1

Decision Algorithm for Restarting Apixaban Post-MI

Step 1: Identify Your Specific Clinical Scenario

Scenario A: MI occurred while ON apixaban for atrial fibrillation or other indication

• Proceed to Step 2 below

Scenario B: MI occurred, now considering starting apixaban

• Do NOT start apixaban unless:
  • Left ventricular thrombus is documented (warfarin preferred, not apixaban) 1
  • High-risk atrial fibrillation exists (CHA₂DS₂-VASc ≥4, or stroke/TIA within 3 months) 1
  • Mechanical valve prosthesis present (warfarin only, not apixaban) 1
  • Recent VTE within 3 months 1

Step 2: Assess for High Thrombotic Risk Indications

You should restart apixaban ONLY if the patient has one of these high-risk conditions: 1

• Atrial fibrillation with CHA₂DS₂-VASc score ≥4 1
• Ischemic stroke or TIA within the past 3 months 1
• Mechanical heart valve (though warfarin is required, not apixaban) 1
• VTE within past 3 months, unprovoked/recurrent VTE, or cancer-associated VTE 1
• Left ventricular assist device (warfarin required) 1

If none of these apply, discontinue apixaban permanently. 1

Step 3: Evaluate Bleeding Risk Factors

Delay restarting if ANY of the following apply: 1

• Bleeding occurred at a critical site (intracranial, intraspinal, intraocular, pericardial, intra-articular, intramuscular with compartment syndrome, retroperitoneal) 1
• Patient is at high risk of rebleeding or death/disability with rebleeding 1
• Source of any recent bleed has not been identified 1
• Surgical or invasive procedure is planned 1

Step 4: Timing of Restart

For patients with high thrombotic risk and acceptable bleeding risk:

• Start parenteral anticoagulation (unfractionated heparin or enoxaparin) within 1-3 days once hemostasis is achieved and patient is clinically stable 1
• Transition to apixaban after 3-5 days of parenteral therapy if bleeding risk remains acceptable 1
• For highest rebleeding risk: Use IV unfractionated heparin due to short half-life and reversibility with protamine 1

Special Considerations for Post-MI Patients

Dual Antiplatelet Therapy (DAPT) Interaction

Critical safety concern: Adding full-dose apixaban (5 mg twice daily) to DAPT after acute coronary syndrome significantly increases major bleeding without reducing ischemic events. 2 The APPRAISE-2 trial was terminated early due to a 2.59-fold increase in major bleeding (hazard ratio 2.59,95% CI 1.50-4.46, P=0.001) with more intracranial and fatal bleeding, without counterbalancing reduction in cardiovascular death, MI, or stroke. 2

If apixaban must be continued for high-risk AF after MI/PCI:

• Use reduced triple therapy duration: Apixaban + P2Y₁₂ inhibitor (clopidogrel preferred over prasugrel/ticagrelor) + aspirin for maximum 1 month, then drop aspirin 1, 3
• Consider apixaban dose reduction to 2.5 mg twice daily if patient meets criteria (age ≥80, weight ≤60 kg, or creatinine ≥1.5 mg/dL) 3
• Standard dose apixaban (5 mg twice daily) showed lower bleeding rates than warfarin in AUGUSTUS trial when combined with P2Y₁₂ inhibitor 3

Left Ventricular Thrombus Exception

If LV thrombus is documented post-MI:

• Warfarin remains the guideline-recommended agent (target INR 2-3) 1
• However, recent evidence suggests apixaban 5 mg twice daily may be non-inferior to warfarin for LV thrombus resolution (92% vs 96% resolution at 6 months, P<0.036 for non-inferiority) 4, 5
• Timing: Continue anticoagulation for at least 3 months, then reassess with echocardiography 1, 4
• Discontinue after >3 months post-MI if LV function recovers 1

Common Pitfalls to Avoid

• Do not restart apixaban for MI alone without a separate high-risk indication for anticoagulation 1
• Do not use triple therapy (apixaban + DAPT) beyond 1 month due to excessive bleeding risk 1, 2
• Do not use apixaban for mechanical valves or LV assist devices—warfarin is required 1
• Do not restart anticoagulation before identifying and treating the bleeding source if bleeding occurred 1
• Do not discontinue apixaban in high-risk AF patients (CHA₂DS₂-VASc ≥4) even after MI, as discontinuation increases risk of stroke, VTE, and mortality 2-fold 6