What is the recommended anticoagulation therapy for a patient with a history of stroke, considering the use of Aspirin (acetylsalicylic acid) and Eliquis (apixaban)?

Anticoagulation Therapy for Patients with History of Stroke

For patients with a history of stroke, the choice between aspirin and apixaban (Eliquis) depends on the stroke etiology - apixaban is strongly recommended for cardioembolic strokes (particularly with atrial fibrillation), while antiplatelet therapy with aspirin is recommended for non-cardioembolic strokes. 1

Determining Stroke Etiology

The first step in selecting appropriate anticoagulation therapy is to determine the stroke etiology:

For Cardioembolic Stroke (with Atrial Fibrillation)

• Oral anticoagulation with apixaban is strongly recommended over antiplatelet therapy 1, 2
• Apixaban has been shown to reduce stroke risk by 21% compared to warfarin and has a better safety profile 3
• In patients with atrial fibrillation and previous stroke/TIA, apixaban significantly reduced stroke or systemic embolism compared to aspirin (2.39% vs 9.16% per year) 4

For Non-Cardioembolic Stroke

• Long-term antiplatelet therapy is indicated 1, 2
• Options include:
  • Aspirin 75-100 mg daily
  • Clopidogrel 75 mg daily
  • Aspirin/extended-release dipyridamole 25/200 mg twice daily

Specific Recommendations by Stroke Type

Cardioembolic Stroke with Atrial Fibrillation

• First-line therapy: Apixaban 5 mg twice daily (or 2.5 mg twice daily for patients ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL) 2, 3
• Apixaban is superior to aspirin for stroke prevention in AF patients, with a 55% relative risk reduction 3, 4
• Even in patients with moderate chronic kidney disease, apixaban reduced stroke by 68% compared to aspirin 5

Non-Cardioembolic Stroke

• First-line therapy: Antiplatelet therapy 1
• Preferred options (in order of preference):
  1. Clopidogrel 75 mg daily or aspirin/extended-release dipyridamole 25/200 mg twice daily 1
  2. Aspirin 75-100 mg daily 1

Special Circumstances

• Minor ischemic stroke (NIHSS ≤3) or high-risk TIA: Consider dual antiplatelet therapy (DAPT) with aspirin 81 mg daily and clopidogrel 75 mg daily for 21 days, followed by single antiplatelet therapy 1, 2
• Embolic Stroke of Undetermined Source (ESUS): Antiplatelet therapy is recommended; oral anticoagulants are not recommended 1
• Extracranial artery dissection: Either antiplatelet therapy or oral anticoagulants for at least 3 months 1

Timing of Initiation

• For antiplatelet therapy after acute ischemic stroke: Start within 48 hours after ruling out intracranial hemorrhage 1, 2
• For oral anticoagulation after cardioembolic stroke: Generally initiate within 1-2 weeks after stroke onset 1
  • Earlier anticoagulation (3-5 days) for patients with small infarcts and low bleeding risk
  • Delayed anticoagulation (2-4 weeks) for patients with large infarcts or hemorrhagic transformation

Common Pitfalls to Avoid

1. Using combined aspirin and apixaban routinely: This combination significantly increases bleeding risk without providing additional benefit in most cases
2. Failing to reassess stroke etiology: Ensure proper diagnostic workup to determine if the stroke is cardioembolic or non-cardioembolic
3. Delaying appropriate therapy: Early initiation of appropriate therapy is crucial for secondary prevention
4. Overlooking medication interactions: Apixaban has drug interactions that may affect its efficacy or safety
5. Not adjusting apixaban dose: Failure to adjust dose based on age, weight, and renal function can lead to adverse events

Monitoring and Follow-up

• For patients on apixaban: Regular monitoring of renal function, signs of bleeding
• For patients on antiplatelet therapy: Monitor for bleeding and medication adherence
• All patients: Aggressive management of other stroke risk factors (hypertension, diabetes, smoking, etc.)

By following these evidence-based recommendations, clinicians can optimize secondary stroke prevention while minimizing bleeding risks in patients with a history of stroke.