Should Plavix (clopidogrel) be taken alongside Eliquis (apixaban) in a post cardiac surgery patient with persistent atrial fibrillation (AFib) and an atrial clip in place, who also has Barrett's esophagus and takes pantoprazole?

Management of Anticoagulation in Post-CABG Patient with AFib, Atrial Clip, and Barrett's Esophagus

Plavix (clopidogrel) should not be taken alongside Eliquis (apixaban) in this post-CABG patient with persistent atrial fibrillation, atrial clip, and Barrett's esophagus who takes pantoprazole. Instead, the patient should be on Eliquis monotherapy for stroke prevention.

Rationale for Anticoagulation Strategy

• Patients with persistent atrial fibrillation following cardiac surgery require anticoagulation therapy to prevent stroke, regardless of the presence of an atrial clip, as AFib increases stroke risk 1
• For patients with AFib who are >12 months post-CABG, antiplatelet therapy (including Plavix) should be discontinued and the patient should be treated with oral anticoagulant alone 1
• The combination of anticoagulation plus antiplatelet therapy substantially increases bleeding risk, especially in a patient with Barrett's esophagus 1, 2

Bleeding Risk Considerations

• Barrett's esophagus represents an increased risk for gastrointestinal bleeding that must be considered in anticoagulation decisions 1
• Apixaban (Eliquis) can cause bleeding which can be serious and rarely may lead to death, as it is a blood thinner medicine that reduces blood clotting 2
• The risk of bleeding is significantly higher when combining anticoagulants with antiplatelet therapy such as Plavix 3, 4
• Continuing pantoprazole is appropriate as it helps reduce the risk of upper gastrointestinal bleeding in patients on anticoagulation 1

Evidence for Anticoagulation in Post-CABG AFib

• Anticoagulation therapy in patients with post-operative atrial fibrillation after cardiac surgery is associated with a small reduction in the risk of arterial thromboembolism (RR 0.83; 95% CI, 0.69-0.99) 4
• However, anticoagulation therapy is also associated with an increased risk of bleeding (RR 3.22; 95% CI, 2.82-3.68) 4
• Direct oral anticoagulants (DOACs) like apixaban are preferred over vitamin K antagonists for non-valvular atrial fibrillation due to lower bleeding risk 1

Specific Recommendations for This Patient

• Discontinue Plavix (clopidogrel) and maintain Eliquis (apixaban) monotherapy for stroke prevention in atrial fibrillation 1
• Standard dosing for apixaban is 5 mg twice daily, with dose reduction 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
• Continue pantoprazole to help mitigate the risk of gastrointestinal bleeding associated with Barrett's esophagus 1
• Regular assessment of bleeding risk factors at each follow-up visit is recommended 1

Important Caveats

• Do not stop taking apixaban without talking to the doctor, as stopping increases the risk of having a stroke 2
• Be vigilant for signs of GI bleeding due to Barrett's esophagus and maintain regular gastroenterology follow-up 1
• If the patient requires procedures in the future, apixaban may need to be temporarily stopped, but this should be managed according to the bleeding risk of the procedure 1, 2
• The presence of an atrial clip does not eliminate the need for anticoagulation if atrial fibrillation persists 1