Does a patient on Eliquis (apixaban) for Deep Vein Thrombosis (DVT) with a history of Coronary Artery Disease (CAD) and a stent also need to be on aspirin?

Antiplatelet Therapy for DVT Patients with CAD and Stent on Apixaban

Yes, this patient should be on aspirin in addition to Eliquis (apixaban), but only if they are within 12 months of their stent placement or have had a recent acute coronary syndrome; after this period, most patients can safely discontinue aspirin and continue anticoagulation alone.

Time-Based Decision Algorithm

Within 12 Months of Stent Placement

Continue dual therapy (apixaban + aspirin) for patients who are still within the guideline-recommended period after coronary stenting 1. The European Society of Cardiology recommends:

• Standard DAPT duration: 6 months for stable CAD with stent, 12 months for acute coronary syndrome 1
• After DAPT completion: Lifelong single antiplatelet therapy (usually aspirin 75-100 mg daily) is recommended for all patients with prior stent placement 1, 2, 3

Beyond 12 Months Post-Stent (Remote Stenting)

Discontinue aspirin and continue apixaban alone for most patients 1. The 2020 ACC Expert Consensus specifically addresses this scenario:

• For patients with remote coronary stenting (>12 months) who require anticoagulation for VTE, stop all antiplatelet therapy and treat with oral anticoagulation alone (DOAC preferred) 1
• This approach reduces bleeding risk while maintaining adequate protection against both thrombotic complications 1

Critical Timing Considerations

If within 1-3 months of stent placement, the situation is more complex and requires triple therapy initially:

• Triple antithrombotic therapy (apixaban + aspirin + clopidogrel) should be used for the shortest possible duration, typically 1 month maximum 1
• After 1 month, transition to dual therapy with apixaban + single antiplatelet (clopidogrel preferred over aspirin) for up to 6-12 months 1
• Use low-dose aspirin (75-81 mg) if aspirin is chosen during combination therapy 1, 2

Bleeding Risk Assessment

High bleeding risk patients require modified approaches 1:

• Consider shorter DAPT duration (3 months or even 1 month) after stenting 1
• Transition to anticoagulation alone as soon as safely possible 1
• Use proton pump inhibitors routinely during any combination antithrombotic therapy 1, 3

Common Pitfalls to Avoid

Do not continue triple therapy beyond 1 month unless there are exceptional high-ischemic-risk features (e.g., left main stenting, history of stent thrombosis), as bleeding risk substantially outweighs benefit 1. The PRECISE-DAPT score ≥25 identifies high bleeding risk patients who should have abbreviated combination therapy 1.

Do not use ticagrelor or prasugrel as part of triple antithrombotic therapy with anticoagulation—only clopidogrel should be used if a P2Y12 inhibitor is needed 1.

Avoid premature discontinuation of antiplatelet therapy within the first 6-12 months post-stent due to risks of stent thrombosis and recurrent MI 1.

Practical Implementation

For your specific patient on apixaban for DVT with CAD and stent history:

1. Determine time since stent placement - this is the critical decision point
2. If <12 months: Continue aspirin 75-100 mg daily + apixaban 1, 2, 3
3. If >12 months: Discontinue aspirin, continue apixaban alone 1
4. If 1-6 months and high bleeding risk: Consider clopidogrel instead of aspirin with apixaban 1

The evidence strongly supports that remote stenting (>12 months) does not require continued antiplatelet therapy when full-dose anticoagulation is indicated for another condition like DVT 1. This represents a paradigm shift from older practices that maintained lifelong aspirin regardless of anticoagulation status.