Yes, she should be on both apixaban (Eliquis) and clopidogrel (Plavix), but aspirin should be stopped immediately.
For this 85-year-old woman with atrial fibrillation after PCI, the recommended regimen is dual therapy: apixaban plus clopidogrel, without aspirin. This approach significantly reduces bleeding risk while maintaining protection against both stroke and stent thrombosis 1, 2, 3.
Recommended Antithrombotic Strategy
Immediate Management
- Start apixaban for atrial fibrillation stroke prevention
- Continue clopidogrel for coronary stent protection
- Discontinue aspirin (if currently taking) to minimize bleeding risk
Apixaban Dosing for This Patient
Given her age of 85 years, apixaban dosing requires careful consideration 1:
Use 2.5 mg twice daily IF she meets ≥2 of these criteria:
- Age ≥80 years (she meets this at 85)
- Body weight ≤60 kg
- Serum creatinine ≥1.5 mg/dL
Use 5 mg twice daily if she meets only one or none of the above criteria 4.
Duration of Dual Therapy
The duration depends on her clinical presentation 1:
If she had stable ischemic heart disease (SIHD) at time of PCI:
- Continue clopidogrel + apixaban for 6 months
- After 6 months: apixaban alone (lifelong for AF)
If she had acute coronary syndrome (ACS) at time of PCI:
- Continue clopidogrel + apixaban for 12 months
- After 12 months: apixaban alone (lifelong for AF)
High bleeding risk exception:
- If deemed high bleeding risk, can discontinue clopidogrel after 3 months (SIHD) or 6 months (ACS), but must weigh stent thrombosis risk 1
Evidence Supporting This Approach
Why Apixaban Over Warfarin
The AUGUSTUS trial demonstrated that apixaban compared to vitamin K antagonists resulted in 1, 2:
- 43% reduction in major bleeding (HR 0.57 for lower bleeding risk patients)
- 28% reduction in major bleeding (HR 0.72 for higher bleeding risk patients)
- Similar rates of stroke, MI, and stent thrombosis
- Lower rates of death or hospitalization
Why Drop Aspirin
The same AUGUSTUS trial showed aspirin added to anticoagulation plus clopidogrel 1, 2:
- Increased bleeding by 81-86% (HR 1.81-1.86) across all risk groups
- Provided no reduction in ischemic events (MI, stroke, stent thrombosis)
- No benefit for cardiovascular death
This finding was consistent regardless of whether patients had ACS treated medically, ACS treated with PCI, or elective PCI 3.
Age Considerations
At 85 years old, this patient is at inherently higher bleeding risk. The evidence supports that apixaban plus a P2Y12 inhibitor without aspirin provides superior safety even in elderly patients with multimorbidity, without compromising efficacy 5.
Critical Pitfalls to Avoid
Do not use triple therapy (apixaban + clopidogrel + aspirin) beyond hospital discharge in most patients. The only exception would be extremely high thrombotic risk (complex PCI, prior MI, extensive disease) AND low bleeding risk—continue aspirin for maximum 1 month only 1, 6.
Do not underdose apixaban. Use the full stroke-prevention dose (5 mg twice daily) unless she meets ≥2 dose-reduction criteria. The 2.5 mg dose studied in trials was only for patients meeting multiple criteria 1.
Do not use prasugrel or ticagrelor. Clopidogrel is the P2Y12 inhibitor of choice in this setting due to lower bleeding risk 7, 6.
Do not stop anticoagulation. The apixaban must continue lifelong for AF stroke prevention. Only the clopidogrel is time-limited 4.
Add a proton pump inhibitor for GI protection given the combination of anticoagulation and antiplatelet therapy 1, 7.
Monitoring Requirements
- Assess renal function, weight, and bleeding risk regularly to ensure appropriate apixaban dosing 1
- Reassess at 6-12 months whether clopidogrel can be safely discontinued based on initial presentation (SIHD vs ACS) 1
- Monitor for any bleeding complications, as elderly patients remain at elevated risk despite optimized regimen 2