Does a patient with a history of mild-to-moderate Coronary Artery Disease (CAD) and minor chronic vessel ischemia, who has undergone minimally invasive mitral valve repair for mitral valve prolapse and developed occasional stable post-operative atrial fibrillation (a fib), require concurrent therapy with aspirin (acetylsalicylic acid) and apixaban (apixaban)?

From the Guidelines

The patient does not need to be on both aspirin and apixaban, and discontinuing aspirin 81 mg daily while continuing apixaban alone is the recommended approach for managing post-operative atrial fibrillation. The typical dosing for apixaban in atrial fibrillation is 5 mg twice daily, though a reduced dose of 2.5 mg twice daily may be appropriate for patients meeting certain criteria (age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 1.

Key Considerations

• Dual therapy with both anticoagulation and antiplatelet therapy significantly increases bleeding risk without providing substantial additional benefit in this clinical scenario 1.
• The patient's previous aspirin use was for primary prevention in the setting of mild-to-moderate coronary artery disease without a history of myocardial infarction or stroke.
• Current evidence suggests that anticoagulation with apixaban alone is sufficient for stroke prevention in atrial fibrillation and will also provide protection against thrombotic events 1.
• Studies such as PIONEER AF-PCI and RE-DUAL PCI have demonstrated that double therapy with an anticoagulant and a P2Y12 inhibitor can reduce the risk of bleeding without increasing the risk of thrombotic events 1.

Clinical Implications

• If the patient develops acute coronary syndrome or undergoes coronary intervention in the future, temporary dual therapy might be reconsidered at that time.
• For now, apixaban monotherapy represents the optimal balance of efficacy and safety, prioritizing the reduction of morbidity, mortality, and improvement of quality of life.
• The decision to discontinue aspirin and continue apixaban alone is supported by the 2019 AHA/ACC/HRS focused update on atrial fibrillation, which emphasizes the importance of minimizing bleeding risk while maintaining effective stroke prevention 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient's Current Condition

The patient has undergone minimally invasive mitral valve repair and is started on apixaban for occasional stable post-op atrial fibrillation (a fib). They were previously on aspirin 81 mg daily due to mild-to-moderate coronary artery disease (CAD) and minor chronic vessel ischemia.

Medication Considerations

• The patient is now on apixaban, a direct oral anticoagulant (DOAC), for atrial fibrillation.
• They were previously taking aspirin for CAD and minor chronic vessel ischemia.
• The question is whether they need to be on both aspirin and apixaban.

Evidence from Studies

• A study published in 2017 2 suggests that the combined use of aspirin and oral anticoagulant therapy in patients with atrial fibrillation and stable coronary artery disease has been questioned due to an increased risk of major bleeding with little to no benefit in preventing ischemic events.
• Another study from 2017 3 compared the effectiveness and safety of apixaban, dabigatran, rivaroxaban, and warfarin in newly diagnosed atrial fibrillation, and found that apixaban had a lower risk of bleeding compared to warfarin.
• A 2020 study 4 found that the comparative effectiveness of DOACs differs substantially between patients with and without a history of stroke or TIA, and apixaban is less effective in patients with a history of stroke or TIA.

Key Points to Consider

• The patient has no history of myocardial infarction (MI) or cerebrovascular accident (CVA) event.
• They have mild-to-moderate CAD and minor chronic vessel ischemia.
• They are now on apixaban for atrial fibrillation.
• The evidence suggests that the combined use of aspirin and oral anticoagulant therapy may increase the risk of major bleeding with little to no benefit in preventing ischemic events.

Decision Making

• Based on the evidence, it is unclear whether the patient needs to be on both aspirin and apixaban.
• However, considering the patient's current condition and the evidence from studies, it may be reasonable to consider discontinuing aspirin and continuing apixaban alone, as the risk of bleeding may be increased with combined therapy 2, 3.