The utilization and safety of apixaban for therapeutic anticoagulation in heart transplant population requiring routine endomyocardial biopsies

Abstract

Purpose: Routine endomyocardial (EM) biopsies pose a challenge in the management of heart transplant recipients requiring anticoagulation. Apixaban is a direct-acting oral anticoagulant (DOAC) with a short half-life allowing for brief interruptions of anticoagulation for procedures. The study objective was to determine the safety and efficacy of apixaban in heart transplant patients undergoing EM biopsies.Methods: This retrospective case series evaluated patients with a heart transplant from April 1, 2017 to July 30, 2020 who were treated with apixaban within 90 days post-transplant. The primary outcome was the occurrence of a bleeding or thrombotic event.Results: A total of 12 patients with >100 biopsies were included. The median age was 54 years (IQR 37-59) with a mean weight of 91 ± 20 kg. There were no bleeding or thrombotic events. During therapy, patients underwent an average of eight biopsies.The median time from transplant to initiation of apixaban was 39.5 days (range 9-77).Therapy was maintained without any need for reversal for a median of 276 days .Conclusions: Apixaban is safe to use for anticoagulation of heart transplant recipients undergoing routine biopsies. Using apixaban allows for a short interruption of therapeutic anticoagulation to accommodate a biopsy without increased risk of bleeding.

A retrospective analysis of anticoagulant safety among heart transplant recipients undergoing endomyocardial biopsy

“…No DOACs were continued uninterrupted in the preprocedural timeframe. Our data further support the conclusions by Lindauer et al., who similarly did not identify any bleeding complications among patients on apixaban undergoing EMB when appropriately held prior to the procedure 20 . While our analysis was not a head‐to‐head comparison, this study suggests that DOACs may have a lower risk of bleeding than warfarin when held prior to the procedure and further demonstrates the utility of DOAC interruptions for invasive cardiovascular procedures.…”

Oral Anticoagulants after Heart Transplantation—Comparison between Vitamin K Antagonists and Direct Oral Anticoagulants

“…In terms of OACs, vitamin K antagonists (VKAs) were the primary OACs for several decades due to the absence of alternatives [ 13 , 14 , 15 , 16 , 17 , 18 ]. The disadvantages of VKAs are a long half-life, a narrow therapeutic window which requires constant laboratory monitoring, multiple drug-drug interactions, and prolonged re–establishment of the therapeutic window after a periprocedural pause [ 13 , 14 , 15 , 16 , 17 , 18 , 19 ].…”

“…In terms of OACs, vitamin K antagonists (VKAs) were the primary OACs for several decades due to the absence of alternatives [ 13 , 14 , 15 , 16 , 17 , 18 ]. The disadvantages of VKAs are a long half-life, a narrow therapeutic window which requires constant laboratory monitoring, multiple drug-drug interactions, and prolonged re–establishment of the therapeutic window after a periprocedural pause [ 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. During the last two decades, direct oral anticoagulants (DOACs) have been approved and clinically introduced which show a number of advantages over VKAs including a shorter half-life, no need for routine laboratory monitoring, fewer drug-drug interactions, and shorter periprocedural drug offset and onset effects [ 13 , 14 , 15 , 16 , 17 , 18 , 19 ].…”

“…The disadvantages of VKAs are a long half-life, a narrow therapeutic window which requires constant laboratory monitoring, multiple drug-drug interactions, and prolonged re–establishment of the therapeutic window after a periprocedural pause [ 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. During the last two decades, direct oral anticoagulants (DOACs) have been approved and clinically introduced which show a number of advantages over VKAs including a shorter half-life, no need for routine laboratory monitoring, fewer drug-drug interactions, and shorter periprocedural drug offset and onset effects [ 13 , 14 , 15 , 16 , 17 , 18 , 19 ]. In addition, several studies showed similar or even better efficacy and safety of DOACs over VKAs for the treatment of AF and VTE in the general population [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ].…”

“…In addition, several studies showed similar or even better efficacy and safety of DOACs over VKAs for the treatment of AF and VTE in the general population [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. However, data on the efficacy and safety of DOACs in HTX recipients are very limited as they are often derived from small sample-size studies [ 17 , 18 , 19 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ].…”