Should a patient with a history of stroke and a recent pulmonary embolism be on aspirin (acetylsalicylic acid) and Eliquis (apixaban)?

Management of a Patient with Previous Stroke and Recent Pulmonary Embolism: Anticoagulation Strategy

A patient with a history of stroke and recent pulmonary embolism should be on apixaban (Eliquis) alone without aspirin, as this provides optimal stroke prevention with the lowest bleeding risk.

Rationale for Anticoagulation with Apixaban Alone

• Apixaban has demonstrated superiority to warfarin in preventing stroke and systemic embolism in patients with atrial fibrillation, with significantly lower rates of hemorrhagic stroke (0.24% vs 0.47% per year) and major bleeding (2.13% vs 3.09% per year) 1
• In patients with a history of stroke, apixaban showed even greater absolute risk reduction compared to aspirin (7% absolute risk reduction over 3.5 years) while maintaining a favorable bleeding profile 2
• The combination of apixaban with aspirin significantly increases bleeding risk without providing substantial additional protection against ischemic events in most patients 3

Why Apixaban is Preferred for This Patient

• Apixaban has demonstrated a 51% reduction in hemorrhagic stroke compared to warfarin in clinical trials, making it particularly valuable for patients with prior stroke 4
• For patients with venous thromboembolism (including pulmonary embolism), apixaban is effective for both treatment and prevention of recurrence 4
• The ARISTOTLE trial showed apixaban was superior to warfarin for stroke prevention with less bleeding, and this benefit was consistent across subgroups including those with prior stroke 4

Risks of Combination Therapy

• Adding aspirin to apixaban substantially increases bleeding risk without providing significant additional protection against stroke in most patients 3
• The AUGUSTUS trial demonstrated that in patients requiring anticoagulation, adding aspirin increased major or clinically relevant non-major bleeding, particularly in patients without prior stroke/TIA 3
• Current guidelines do not recommend routine combination of anticoagulants with antiplatelet therapy for patients with a history of stroke unless there are specific additional indications 4

Special Considerations

• If the patient has had a recent coronary intervention or acute coronary syndrome, limited-duration triple therapy might be considered, but the duration should be minimized 3
• For patients with mechanical heart valves, apixaban is contraindicated, and warfarin would be preferred 4
• Renal function should be assessed, as apixaban dosing may need adjustment in patients with severe renal impairment 1

Monitoring and Follow-up

• Regular assessment for bleeding complications is essential, with particular attention to gastrointestinal bleeding which may be increased with apixaban 1
• Unlike warfarin, apixaban does not require routine INR monitoring, improving quality of life and reducing healthcare visits 4
• Patient education about consistent medication adherence is crucial, as missed doses of apixaban can significantly increase stroke risk due to its relatively short half-life 1

Common Pitfalls to Avoid

• Avoid combining apixaban with aspirin unless there is a compelling indication (such as recent coronary stenting), as this significantly increases bleeding risk 3
• Do not discontinue anticoagulation after an arbitrary time period for pulmonary embolism if stroke risk factors persist 4
• Ensure appropriate dosing of apixaban based on age, weight, and renal function to optimize the benefit-risk profile 1