Oral anticoagulation management — KFP-style written assessment

KFP 1 (10 marks)

A 70-year-old woman with AF on apixaban 5 mg twice daily (eGFR 55 mL/min/1.73 m²) is listed for elective knee arthroscopy with moderate bleeding risk. She asks whether she needs 'blood-thinner injections around the operation'. ^[1]

1. State the apixaban interruption window for this procedure. (2)
2. Answer her bridging question with BRIDGE numbers. (4) ^[1]
3. When does bridging still have a role? (2) ^[1]
4. When does she restart apixaban? (2)

Model answers

1. Stop apixaban 48–72 hours before surgery (48 hours at eGFR above 50 with moderate bleed risk; extend to 72 hours if higher risk). ^[1]
2. No bridging. In BRIDGE (1884 AF patients), arterial thromboembolism was 0.4% no-bridging versus 0.3% LMWH bridging (noninferior), while major bleeding was 1.3% versus 3.2% — bridging nearly tripled bleeding without preventing clots. ^[1]
3. Mechanical heart valves and the highest thrombotic-risk profiles (recent stroke, prior thrombosis on therapy) remain bridging territory after individualised assessment. ^[1]
4. Restart within 24–72 hours postoperatively depending on haemostasis; prophylactic-dose timing per surgical team. ^[1]