When to discontinue Eliquis (apixaban) after cardiac stent placement?

From the Guidelines

The decision to discontinue Eliquis (apixaban) after cardiac stent placement should be made by your cardiologist based on your specific clinical situation, but typically, for patients without an indication for oral anticoagulation, dual antiplatelet therapy (DAPT) is recommended for up to 6 months after PCI-stenting, and Eliquis is not necessary unless there's another indication such as atrial fibrillation. When considering discontinuation of Eliquis post cardiac stent placement, it's crucial to weigh the risks of bleeding against the risks of thrombotic events, as outlined in the 2024 ESC guidelines for the management of chronic coronary syndromes 1. For patients at high bleeding risk but not at high ischemic risk, discontinuing DAPT 1–3 months after PCI and continuing with single antiplatelet therapy may be recommended, according to the same guidelines 1. However, for patients with atrial fibrillation who have undergone stent placement, the management of antithrombotic therapy is more complex, and guidelines suggest that triple therapy (Eliquis plus DAPT) is usually limited to 1-6 months depending on bleeding risk, then reduced to dual therapy (Eliquis plus a single antiplatelet) for a period before potentially transitioning to Eliquis alone, as discussed in the context of antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention 1. Key considerations include:

• The patient's specific clinical situation, including the presence of atrial fibrillation or other indications for anticoagulation
• The risk of bleeding versus the risk of thrombotic events
• The type of stent placed and the complexity of the procedure
• The patient's renal function, as it affects the half-life of Eliquis and other non-vitamin K antagonist oral anticoagulants (NOACs) 1. In general, stopping Eliquis prematurely increases stroke risk in atrial fibrillation patients, while continuing it unnecessarily increases bleeding risk, emphasizing the need for careful, individualized decision-making. Regular follow-up appointments are essential to reassess the need for anticoagulation, and patients should never stop Eliquis without medical guidance, as this could lead to serious complications including stent thrombosis or stroke.

From the Research

Discontinuation of Eliquis Post Cardiac Stent Placement

• The decision to discontinue Eliquis (apixaban) post cardiac stent placement depends on various factors, including the patient's thrombotic risk, bleeding risk, and individual preferences 2, 3.
• Current guidelines suggest that dual therapy, consisting of a single antiplatelet agent and an oral anticoagulant, is effective and associated with less bleeding risk than triple therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI) with stent placement 2, 3.
• Aspirin should be discontinued in most patients at discharge, but can be continued for up to 1 month in patients with a high risk of thrombosis 2, 3.
• Dual therapy should be continued for 6 to 12 months, depending on the patient's ischemic and bleeding risk profile, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone 3.
• The optimal duration of treatment with dual antiplatelet therapy after coronary stent placement is not known, but current guidelines recommend treatment for at least 6-12 months after coronary stent placement in suitable patients 4.

Considerations for Patients on Oral Anticoagulants

• The optimal antiplatelet regimen for patients on oral anticoagulants undergoing coronary stenting continues to be controversial, and the balance between reducing stroke, stent thrombosis, and myocardial infarction without increasing major bleeding requires individualized therapy 5.
• In patients with a low risk of stroke, dual antiplatelet therapy alone may be sufficient, while those at moderate to high risk of stroke may require dose-adjusted oral anticoagulation 5.
• The use of proton pump inhibitors, tight control of the international normalized ratio (INR), and limited duration of dual antiplatelet therapy can reduce the bleeding risk without increasing stroke or stent thrombosis 5.

Recommendations for Antithrombotic Therapy

• A non-vitamin K antagonist oral anticoagulant, such as apixaban, is recommended as the oral anticoagulation of choice in patients with atrial fibrillation undergoing PCI 3.
• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period, after which the default strategy is to stop aspirin and continue treatment with a P2Y12 inhibitor and an oral anticoagulant 3.
• The WOEST trial suggested that clopidogrel alone plus an oral anticoagulant resulted in an equal outcome with a significantly lower bleeding risk when compared to triple therapy, but this regimen has not been widely adopted as the standard of care 5.