Perioperative Apixaban: Bleeding, Clotting, or Both?
Abstract
Anticoagulation for Subclinical Atrial Fibrillation
Recently, the ARTESIA study addressed this question in a randomized trial of 4,012 patients with subclinical atrial fibrillation identified by an implanted device, and CHA2DS2-VASc score of at least 3.4 Subclinical atrial fibrillation was defined as at least 1 episode lasting 6 minutes up to 24 hours.4 Patients were allocated randomly to apixaban or aspirin, and over a median of 3.5 years, apixaban significantly decreased stroke and other systemic embolic phenomena compared to aspirin (0.78% v
Implications for Cardiac Anesthesia
Although the ARTESIA trial relied on the use of patients with implanted cardiac devices to diagnose subclinical atrial fibrillation, the results potentially could motivate clinicians to identify subclinical atrial fibrillation in other settings; for example, patients who develop a brief episode of atrial fibrillation during continuous monitoring on a telemetry floor or during anesthesia. Factor Xa inhibitors, including apixaban, are being prescribed with increasing frequency—1 large literature
Reversal of Factor Xa Inhibitors
Four-factor prothrombin complex concentrates and the specific factor Xa reversal agent andexanet alfa are used to reverse the bleeding effect of factor Xa inhibitors.6,7 Despite their frequent use, there is controversy in the literature with regard to the efficacy of 4-factor prothrombin complex concentrates in reversing factor Xa inhibitors.8 Additionally, dialysis has proven to be ineffective at clearing factor Xa inhibitors.6,7,9 The reversal of apixaban and other factor Xa inhibitors took a
Factor Xa Inhibitors in Elective Surgery
For elective procedures or those that can be postponed for a brief period, current evidence suggests that factor Xa inhibitors can be held for 1 day prior to low-bleeding-risk procedures, and 2 days for high-bleeding-risk procedures.13 In patients with significantly depressed renal function (estimated glomerular filtration rate <30 mL/min), longer preoperative holding periods may be necessary.13 Factor Xa inhibitors can be restarted after 1 day in low-risk bleeding procedures, and after 2-to-3
Conclusions
Increasing atrial fibrillation, in general, and the broader use of anticoagulation to include patients with asymptomatic subclinical atrial fibrillation will likely further expand the routine use of factor Xa inhibitors.4 The increased use of these medications will require clinicians to be even more vigilant about their presence and understand the options for management in the perioperative period. For cardiac anesthesiologists, the use of andexanet alfa may prevent life-threatening bleeding