Is aspirin and Eliquis (apixaban) necessary for a patient with atrial fibrillation (AFib) and a pacemaker?

Management of Anticoagulation in Atrial Fibrillation with Pacemaker

For patients with atrial fibrillation and a pacemaker, Eliquis (apixaban) alone is recommended as the anticoagulant of choice, and aspirin should NOT be routinely added unless there is a specific indication such as recent coronary stenting. 1

Anticoagulation in Atrial Fibrillation

Primary Recommendation

• Apixaban (Eliquis) is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation 2
• The presence of a pacemaker alone does not change the anticoagulation recommendation or necessitate additional antiplatelet therapy 1
• Adding aspirin to anticoagulation increases bleeding risk without providing additional stroke prevention benefit in most AF patients 1, 3

Evidence Supporting Apixaban Monotherapy

• In the ARISTOTLE trial, apixaban was superior to warfarin for stroke prevention with fewer bleeding events 1
• Apixaban demonstrated significant reduction in:
  • Overall strokes (both ischemic and hemorrhagic) 1
  • Systemic emboli 1
  • Major bleeding events 1
  • Intracranial hemorrhage 1
  • All-cause mortality 1

Combination Therapy Considerations

• Dual therapy with anticoagulation plus antiplatelet therapy significantly increases bleeding risk 1
• The AVERROES study showed apixaban was superior to aspirin alone for stroke prevention with similar bleeding rates 1
• In patients with AF without recent acute coronary syndrome or coronary stenting, adding aspirin to anticoagulation:
  • Increases major bleeding risk 3
  • Does not provide additional stroke prevention benefit 1, 3

Special Considerations

When Combination Therapy May Be Indicated

• Recent coronary stenting (typically limited duration of dual therapy) 1
• Acute coronary syndrome 1
• In these cases, the duration of dual therapy should be minimized to reduce bleeding risk 1

Monitoring and Safety

• Renal function should be regularly monitored as apixaban dosing depends on renal function 1
• Standard apixaban dose is 5 mg twice daily 1
• Reduced dose of 2.5 mg twice daily is recommended if patient has at least 2 of the following: 1
  • Age ≥80 years
  • Body weight ≤60 kg
  • Serum creatinine ≥1.5 mg/dL

Important Warnings

• Apixaban can cause bleeding which can be serious and rarely may lead to death 2
• Bleeding risk is higher when combined with other medications that increase bleeding risk, including aspirin 2
• Do not stop taking apixaban without talking to your doctor as this increases stroke risk 2

Common Pitfalls to Avoid

• Adding aspirin "just to be safe" - this actually increases bleeding risk without additional stroke prevention benefit 1, 3
• Assuming a pacemaker itself requires dual therapy - the pacemaker alone is not an indication for combination therapy 1
• Stopping anticoagulation without appropriate bridging for procedures 2
• Failing to adjust apixaban dosing based on age, weight, and renal function 1

In summary, for patients with atrial fibrillation and a pacemaker, apixaban monotherapy is the recommended approach for stroke prevention. Aspirin should only be added when there is a specific indication such as recent coronary stenting, and even then, for the shortest duration necessary to minimize bleeding risk.