What is the recommended duration of anticoagulation with Eliquis (apixaban) for a patient after a 5-vessel Coronary Artery Bypass Graft (CABG)?

Duration of Apixaban (Eliquis) After 5-Vessel CABG

Apixaban (Eliquis) is not routinely recommended for long-term use following CABG surgery; instead, lifelong aspirin therapy is the standard of care, with possible addition of a P2Y12 inhibitor for the first year in high-risk patients.

Standard Antiplatelet Therapy After CABG

Immediate Post-CABG Period

• Aspirin (75-100 mg daily) should be resumed immediately after surgery and continued lifelong 1
• This is considered standard of care for all CABG patients to reduce the risk of graft occlusion and cardiovascular events 2

Extended Antiplatelet Therapy

• For patients with no specific indication for anticoagulation:
  • Single antiplatelet therapy with aspirin should be continued indefinitely
  • In high-risk patients, dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel may be considered for up to 12 months 3

Anticoagulation After CABG

Specific Indications for Anticoagulation

Anticoagulation with apixaban or other direct oral anticoagulants (DOACs) after CABG is only indicated in patients with:

1. Atrial Fibrillation

   • In post-CABG atrial fibrillation that persists more than 24 hours, warfarin anticoagulation for 4 weeks is recommended 2
   • If long-term anticoagulation is needed, a DOAC like apixaban may be used

2. Recent Anterior MI with Wall Motion Abnormality

   • Long-term (3-6 months) anticoagulation is indicated 2

3. Venous Thromboembolism (VTE)

   • Duration depends on whether the VTE was provoked (3 months) or unprovoked (indefinite) 2
   • For patients on indefinite anticoagulation who are >6 months from their VTE event, reduced-dose apixaban (2.5 mg twice daily) may be considered 2

No Routine Anticoagulation

• There is weak evidence for post-CABG anticoagulation in patients without specific indications 3
• The COMPASS-CABG study showed that rivaroxaban plus aspirin or rivaroxaban alone did not reduce graft failure rates compared to aspirin alone 4
• Some evidence suggests patients receiving NOACs after CABG may have increased risk of developing effusions requiring invasive interventions compared to warfarin 5

Management Algorithm for Post-CABG Antithrombotic Therapy

1. For patients with no specific indication for anticoagulation:

   • Start/resume aspirin 75-100 mg daily immediately after surgery
   • Continue aspirin indefinitely
   • Consider adding clopidogrel for 12 months in high-risk patients

2. For patients with atrial fibrillation:

   • If AF persists >24 hours post-CABG: Warfarin for 4 weeks 2
   • For long-term management:
     • If <6 months post-CABG: Continue aspirin and add apixaban
     • If >12 months post-CABG: Apixaban alone can be used 2

3. For patients with recent VTE requiring anticoagulation:

   • If <12 months since CABG: Continue aspirin (<100 mg/day) and add apixaban
   • If >12 months since CABG: Stop aspirin and use apixaban alone 2

Common Pitfalls and Caveats

1. Bleeding Risk:

   • Combining antiplatelet and anticoagulant therapy significantly increases bleeding risk
   • When anticoagulation is required, consider stopping aspirin after 12 months post-CABG 2

2. Medication Interruption for Procedures:

   • For low bleeding risk procedures: Interrupt apixaban 24 hours before (if CrCl >30 mL/min) 2
   • For high bleeding risk procedures: Interrupt apixaban 3 days before (if CrCl >30 mL/min) 2

3. Resumption After Procedures:

   • For low bleeding risk procedures: Resume apixaban 24 hours after procedure
   • For high bleeding risk procedures: Resume apixaban 48-72 hours after procedure 2

In conclusion, there is no standard duration of apixaban therapy specifically for post-CABG patients unless there is a separate indication for anticoagulation such as atrial fibrillation or VTE. The standard approach remains lifelong aspirin therapy with possible addition of a P2Y12 inhibitor for the first year in high-risk patients.