Is it safe for a 91-year-old patient who had coronary artery bypass grafting (CABG) x 3 and is on heparin, Eliquis (apixaban), and aspirin (acetylsalicylic acid, ASA)?

Anticoagulation Management in a 91-Year-Old Post-CABG Patient

The combination of heparin, Eliquis (apixaban), and aspirin is not recommended for a 91-year-old patient who has undergone CABG surgery due to the extremely high bleeding risk that outweighs any potential antithrombotic benefit. 1

Risk Assessment

Bleeding Risk Factors

• Advanced age (91 years) is a major independent risk factor for bleeding complications
• Triple antithrombotic therapy (heparin + apixaban + ASA) creates an excessive anticoagulation state
• Post-surgical status (CABG) already carries inherent bleeding risks

Current Guidelines on Post-CABG Anticoagulation

The American College of Cardiology and American Heart Association recommend:

• Aspirin alone (100-325 mg daily) should be initiated within 6 hours postoperatively and continued indefinitely to prevent saphenous vein graft closure 1
• For most post-CABG patients, aspirin monotherapy is the standard of care for long-term management 1
• Triple therapy with aspirin, clopidogrel, and an oral anticoagulant should be limited to 1 month maximum, even in patients at high thrombotic risk 2

Appropriate Anticoagulation Strategy

Recommended Approach

1. Discontinue heparin after the immediate post-operative period

   • Routine post-procedural intravenous heparin administration is not recommended due to lack of evidence of definite benefits and potential for increased bleeding complications 2

2. Choose ONE anticoagulant only if anticoagulation is absolutely necessary:

   • If the patient has atrial fibrillation or another indication for anticoagulation, use either:
     • Apixaban alone (consider reduced dose of 2.5 mg twice daily due to age ≥80 years) 3
     • OR aspirin alone (not both)

3. Avoid triple therapy (heparin + apixaban + ASA) as this creates an excessive risk of bleeding, particularly in this elderly patient 2

Special Considerations for Elderly Patients

• For patients ≥80 years of age, apixaban dosage should be reduced to 2.5 mg twice daily 3
• The bleeding risk substantially increases with age, especially above 75 years
• The unfavorable patient profile for combination anticoagulant and antiplatelet therapy specifically lists "advanced age" as a major risk factor 2

Common Pitfalls to Avoid

1. Overanticoagulation: Using multiple anticoagulants/antiplatelets simultaneously in elderly patients dramatically increases bleeding risk without proportional thrombotic benefit

2. Failure to adjust dosing: Not reducing apixaban dose in elderly patients (≥80 years) increases bleeding risk

3. Prolonged triple therapy: Continuing triple therapy beyond the immediate post-operative period is not supported by evidence and significantly increases bleeding risk

4. Ignoring age-related risks: Advanced age (91 years) is itself a major risk factor for bleeding that must be considered in anticoagulation decisions

Monitoring Recommendations

If anticoagulation is deemed necessary:

• Monitor for signs of bleeding (bruising, hematuria, melena, hemoptysis)
• Regular complete blood count to assess for occult blood loss
• Renal function monitoring as impaired renal function can increase anticoagulant drug levels

Remember that in this 91-year-old post-CABG patient, the bleeding risk from triple therapy far outweighs any potential antithrombotic benefit. A simplified regimen with a single agent is strongly preferred.