Should a patient with a history of cerebrovascular accident (CVA) on Eliquis (apixaban) also be on aspirin or another oral antiplatelet drug?

Should a 55-Year-Old Male with CVA History on Eliquis Also Take Aspirin or Another Antiplatelet?

No, this patient should NOT be on aspirin or another antiplatelet drug in addition to Eliquis (apixaban) for stroke prevention alone. Anticoagulation with apixaban is superior to antiplatelet therapy for secondary stroke prevention in patients with a history of CVA, and adding an antiplatelet agent significantly increases bleeding risk without providing additional benefit for stroke prevention 1.

Primary Recommendation

For patients with a history of noncardioembolic ischemic stroke or TIA, oral anticoagulation is NOT recommended over antiplatelet therapy 1. However, if this patient is on Eliquis, it suggests either:

• Atrial fibrillation (AF) is present, OR
• Another indication for anticoagulation exists

If Atrial Fibrillation is Present

Anticoagulation alone with apixaban is the correct treatment 1:

• Oral anticoagulation is recommended over aspirin alone (Grade 1B) 1
• Oral anticoagulation is recommended over combination therapy with aspirin and clopidogrel (Grade 1B) 1
• Adding aspirin to anticoagulation increases major bleeding risk by 3-6 fold without reducing stroke risk 2

Specific Scenarios Where Antiplatelet Addition May Be Considered

Recent Coronary Intervention (Within 12 Months)

If the patient had recent acute coronary syndrome (ACS) or stent placement:

• Stop aspirin and continue clopidogrel 75 mg daily with apixaban for 1-6 months post-intervention 1
• Triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) should be limited to ≤30 days maximum and only in highest-risk patients 1
• After 12 months post-ACS, discontinue all antiplatelet therapy and continue anticoagulation alone 1

Recent Carotid Intervention

If carotid stenting occurred within 1-3 months:

• Stop aspirin, continue clopidogrel with apixaban during the standard DAPT period (1-3 months) 1
• After this period, discontinue clopidogrel and continue apixaban alone 1

If carotid endarterectomy was performed:

• Stop all antiplatelet therapy 3-14 days post-surgery when bleeding risk is acceptable 1
• Continue apixaban alone 1

Peripheral Artery Disease (PAD)

If symptomatic PAD without recent revascularization:

• Consider low-dose rivaroxaban 2.5 mg twice daily plus aspirin 81 mg (this is a different regimen than apixaban monotherapy) 1
• However, this increases major bleeding risk and the benefit is uncertain 1
• Apixaban alone remains the preferred strategy for stroke prevention 1

Critical Safety Considerations

Bleeding risk with combination therapy:

• Triple therapy causes more bleeding than dual therapy (P2Y12 inhibitor + anticoagulant) with no additional thrombotic protection 1, 2
• Major bleeding risk increases from 1.16% to 2.26% annually when adding antiplatelet to anticoagulation 3
• A proton pump inhibitor (PPI) should be added if any antiplatelet is used with apixaban to reduce GI bleeding risk by 68% 2

What to Assess in This Patient

Determine the indication for Eliquis:

• Is atrial fibrillation present (paroxysmal or persistent)? 1
• Is there another indication for anticoagulation (VTE, mechanical valve)? 1
• Was there recent coronary or carotid intervention? 1

If the CVA was noncardioembolic and no AF is present:

• Apixaban is NOT the standard treatment 1
• Single antiplatelet therapy (aspirin 75-100 mg daily, clopidogrel 75 mg daily, or aspirin/extended-release dipyridamole) is recommended instead 1
• Switching from apixaban to antiplatelet monotherapy should be considered 1

Common Pitfalls to Avoid

• Do not add aspirin "just to be safe" - this dramatically increases bleeding without benefit for stroke prevention alone 1, 2
• Do not continue antiplatelet therapy beyond 12 months post-coronary intervention in patients requiring anticoagulation 1
• Do not use dual antiplatelet therapy (aspirin + clopidogrel) in patients with stroke/TIA history - this is specifically NOT recommended 1
• Ensure the indication for apixaban is appropriate - if prescribed solely for noncardioembolic stroke prevention, this is off-label and not guideline-supported 1