When to use Aspirin (acetylsalicylic acid), Plavix (clopidogrel), Eliquis (apixaban), Xarelto (rivaroxaban), or Brilinta (ticagrelor) and what is the typical duration of treatment?

Antiplatelet and Anticoagulant Therapy Selection and Duration Guidelines

The choice of antiplatelet or anticoagulant medication should be based primarily on the underlying condition, with specific agents selected according to clinical scenario and duration determined by balancing thrombotic and bleeding risks. 1

Aspirin (Acetylsalicylic Acid)

• Recommended as lifelong therapy (75-100mg daily) for patients with prior MI, remote PCI, or significant obstructive coronary artery disease 2
• Serves as the foundation of antiplatelet therapy in coronary artery disease, with low-dose (75-100mg) recommended when used in combination therapy to minimize bleeding risk 2, 1
• After CABG surgery, aspirin should be initiated post-operatively as soon as bleeding risk allows and continued lifelong 2
• In patients with atrial fibrillation undergoing PCI, aspirin should be discontinued early (≤1 week) when used with OAC and clopidogrel 2

Clopidogrel (Plavix)

• Recommended (75mg daily) as a safe and effective alternative to aspirin monotherapy in patients with prior MI or remote PCI 2
• Preferred P2Y12 inhibitor when combination therapy with anticoagulants is needed 1
• Loading dose of 600mg recommended for stable CAD patients undergoing coronary stent implantation 2
• Recommended for ACS patients who cannot receive ticagrelor or prasugrel, including those with prior intracranial bleeding or requiring oral anticoagulation 2
• Should be discontinued at least 5 days before CABG if surgery cannot be delayed 2

Ticagrelor (Brilinta)

• Recommended over clopidogrel for ACS patients unless bleeding risk outweighs potential ischemic benefit 2
• Not recommended as part of triple therapy with aspirin and oral anticoagulant 2
• In patients previously on clopidogrel with ACS, switching to ticagrelor is recommended early after hospital admission (180mg loading dose) 2
• Should be discontinued at least 3-5 days before CABG if surgery cannot be delayed 2

Prasugrel

• Recommended for P2Y12 inhibitor-naïve patients with NSTE-ACS or STEMI undergoing PCI 2
• Contraindicated in patients with previous intracranial hemorrhage, previous ischemic stroke/TIA, or ongoing bleeds 2
• Not recommended for patients ≥75 years of age or with body weight <60kg due to increased bleeding risk 3
• Not recommended in medically managed ACS patients 2
• Should be discontinued at least 7 days before CABG if surgery cannot be delayed 2

Apixaban (Eliquis) and Rivaroxaban (Xarelto)

• Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists when anticoagulation is needed 1
• Apixaban is preferred over rivaroxaban due to lower bleeding risk when anticoagulation is required 1
• For atrial fibrillation without CAD or PCI, DOAC monotherapy is preferred, avoiding unnecessary antiplatelet therapy 1
• In patients with indication for oral anticoagulation who undergo PCI, DOAC plus clopidogrel (without aspirin) is recommended after initial triple therapy period 2

Duration of Therapy

Dual Antiplatelet Therapy (DAPT)

• For Stable CAD with PCI:

  • Default duration is 1-6 months depending on bleeding risk 2
  • For bare metal stents (BMS): 1 month of DAPT followed by single antiplatelet therapy 2
  • For drug-eluting stents (DES): 3-6 months of DAPT (minimum 3 months for -limus stents, 6 months for -taxel stents) 2

• For ACS with PCI:

  • DAPT recommended for 12 months unless excessive bleeding risk exists 2
  • For high bleeding risk patients, shorter duration (3-6 months) may be considered 3
  • For low bleeding risk patients who tolerate DAPT well, extended therapy beyond 12 months may be considered 2, 4

• For ACS with Medical Management:

  • DAPT recommended for 12 months with ticagrelor preferred over clopidogrel unless bleeding risk is high 2

Triple Therapy (OAC + DAPT)

• For patients with atrial fibrillation undergoing PCI:
  • Initial triple therapy for shortest duration possible (typically ≤30 days) 1, 5
  • Followed by dual therapy (OAC + P2Y12 inhibitor, preferably clopidogrel) for up to 12 months 1, 5
  • Then OAC monotherapy thereafter 2, 5

Special Considerations

• High Bleeding Risk:

  • Shorter DAPT duration (1-3 months) recommended 2
  • Proton pump inhibitor recommended with DAPT to reduce gastrointestinal bleeding risk 2
  • Radial over femoral access for coronary procedures when possible 2

• Perioperative Management:

  • For non-cardiac surgery, continue aspirin if bleeding risk allows 2
  • Do not discontinue DAPT within first month after stent implantation 2
  • For DOAC interruption, timing depends on drug half-life and renal function 6

• Common Pitfalls to Avoid:

  • Unnecessary combination therapy increases bleeding risk without proportional reduction in thrombotic events 1
  • Extended triple therapy significantly increases bleeding risk 1
  • Using prasugrel in patients with history of stroke/TIA or those ≥75 years or <60kg 3

Remember that regular evaluation of the need for continued dual or triple therapy is essential as thrombotic risk decreases over time while bleeding risk remains constant 1.