How to transition from Plavix (clopidogrel) to Eliquis (apixaban) in a patient with atrial fibrillation following coronary artery bypass grafting (CABG) surgery?

Transitioning from Plavix to Eliquis in Atrial Fibrillation Patients After CABG Surgery

When transitioning from Plavix (clopidogrel) to Eliquis (apixaban) in a patient with atrial fibrillation following CABG surgery, stop Plavix and start Eliquis immediately without overlap, as this approach minimizes bleeding risk while maintaining thromboembolic protection.

Assessment of Patient Risk Factors

• Evaluate stroke risk using the CHA₂DS₂-VASc score to determine the necessity of anticoagulation therapy, as post-CABG AF patients are not considered "low risk" 1
• Assess bleeding risk using tools such as the HAS-BLED score, with particular attention to modifiable bleeding risk factors 1
• Consider the time elapsed since CABG surgery, as this affects anticoagulation management decisions 2

Timing of Transition

• For patients <12 months post-CABG with AF requiring oral anticoagulation, stop aspirin (if being used), continue clopidogrel, and start apixaban 2
• For patients >12 months post-CABG with AF, discontinue all antiplatelet therapy (including Plavix) and transition directly to apixaban monotherapy 2, 1
• The risk of stent thrombosis is highest in the first 4-6 weeks after coronary intervention, which may influence the timing of transition 2

Specific Transition Protocol

• If <12 months post-CABG:

  • Day 1: Continue Plavix 75 mg daily and start Eliquis at appropriate dose (typically 5 mg twice daily) 2, 1
  • Continue this combination for the remainder of the 12-month post-CABG period 2
  • After 12 months: Discontinue Plavix and continue Eliquis monotherapy 2

• If >12 months post-CABG:

  • Day 1: Stop Plavix and start Eliquis at appropriate dose (5 mg twice daily or 2.5 mg twice daily if dose reduction criteria are met) 2, 1
  • Continue Eliquis monotherapy indefinitely 2

Dosing Considerations for Eliquis

• Standard dosing for apixaban is 5 mg twice daily 1
• Reduce dose to 2.5 mg twice daily if the patient has any two of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1
• No bridging with heparin is required during this transition 2

Monitoring and Follow-up

• Monitor for signs of bleeding or thromboembolism during the transition period 1
• Schedule follow-up within 2-4 weeks after transition to assess for adverse effects 1
• Perform regular assessment of bleeding risk factors at each follow-up visit 1
• More frequent monitoring is necessary for patients with high bleeding risk (HAS-BLED ≥3) 1

Important Considerations and Pitfalls

• Avoid triple therapy (oral anticoagulant + dual antiplatelet therapy) due to excessive bleeding risk 1
• Post-operative AF after CABG is associated with increased risk of late AF, stroke, and mortality, emphasizing the importance of appropriate anticoagulation 3, 4
• Recent meta-analysis shows that oral anticoagulation in post-CABG AF patients is associated with increased bleeding risk, so careful monitoring is essential 5
• Do not base anticoagulation decisions solely on the perceived success of rhythm control strategies for AF 1
• New-onset POAF is associated with negative long-term outcomes including increased risk of ischemic stroke, thromboembolism, and heart failure hospitalization 6