Guidelines for Aspirin with Eliquis in History of CAD with CABG
For patients with a history of CAD who have undergone CABG and require anticoagulation with Eliquis (apixaban), lifelong aspirin 75-100 mg daily is recommended in addition to the appropriate dose of apixaban, unless there is an excessive risk of bleeding. 1
Antithrombotic Management After CABG
Standard Post-CABG Antiplatelet Therapy
- Aspirin 75-100 mg daily is recommended lifelong after CABG to improve saphenous vein graft patency and reduce mortality, MI, stroke, renal failure, and bowel infarction 1
- Aspirin should be initiated within 6 hours postoperatively and continued indefinitely 1
- Aspirin significantly improves saphenous vein graft patency rates, particularly during the first postoperative year 1
When Oral Anticoagulation is Required (e.g., Eliquis/apixaban)
For patients who require oral anticoagulation with Eliquis (apixaban) due to conditions like atrial fibrillation:
Standard approach:
- Apixaban at the appropriate therapeutic dose (based on indication)
- Aspirin 75-100 mg daily 1
For patients at high bleeding risk:
- Consider apixaban alone without aspirin after initial period of combination therapy 1
- This decision should be based on careful assessment of thrombotic vs. bleeding risks
Special Considerations
Bleeding Risk Management
- A proton pump inhibitor is recommended for patients on combined antithrombotic therapy to reduce gastrointestinal bleeding risk 1
- For patients with very high bleeding risk, the benefits of combined therapy must be carefully weighed against risks
Aspirin Alternatives
- If aspirin intolerance or allergy exists, clopidogrel 75 mg daily is a reasonable alternative 1
- For true aspirin hypersensitivity, aspirin desensitization may be considered 2
Duration Considerations
- After an initial period (typically 6-12 months) of dual antithrombotic therapy in most patients with atrial fibrillation who have undergone CABG, oral anticoagulation alone may be preferred over continued dual therapy in patients at higher bleeding risk 1
Important Caveats
- The combination of apixaban with aspirin increases bleeding risk compared to either agent alone
- The COMPASS-CABG study showed that adding rivaroxaban (another direct oral anticoagulant) to aspirin did not reduce graft failure rates but was associated with similar reductions in major adverse cardiovascular events as seen in the larger COMPASS trial 3
- Avoid triple therapy (dual antiplatelet therapy plus anticoagulation) whenever possible due to excessive bleeding risk 1
- Regular reassessment of bleeding risk is essential, as bleeding risk may change over time
By following these guidelines, clinicians can optimize antithrombotic therapy for patients with a history of CAD and CABG who require anticoagulation with Eliquis, balancing the prevention of thrombotic events with minimizing bleeding complications.