Aspirin After 12 Months Post-DES in Patients on Apixaban
Yes, aspirin should be continued indefinitely after drug-eluting stent placement, even beyond 12 months and even when the patient is on Eliquis (apixaban). The P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) can be discontinued after 12 months in most cases, but aspirin remains a lifelong therapy for coronary stent patients. 1, 2
Core Antiplatelet Recommendations Post-DES
After PCI with drug-eluting stent placement, aspirin should be continued indefinitely regardless of other antithrombotic therapy. 1 This is a Class I, Level A recommendation from the American College of Cardiology/American Heart Association guidelines. 1
The dual antiplatelet therapy (DAPT) regimen consists of:
- Aspirin 81 mg daily indefinitely (preferred dose over higher maintenance doses) 1
- P2Y12 inhibitor for at least 12 months after DES implantation in patients not at high bleeding risk 1, 2
After the initial 12-month DAPT period, the P2Y12 inhibitor may be discontinued, but aspirin must continue. 1
The Critical Role of Aspirin Beyond 12 Months
The guidelines are unequivocal that aspirin continuation is essential even after the mandatory DAPT period ends. 1 This recommendation holds true regardless of whether the patient is on anticoagulation therapy like apixaban. 1
Premature discontinuation of antiplatelet therapy dramatically increases cardiovascular risk, with stent thrombosis resulting in death or myocardial infarction in 64.4% of cases, with mortality rates of 20-45%. 2, 3 Even beyond the first year, the risk of late stent thrombosis persists, particularly with drug-eluting stents which show delayed endothelialization. 1
Managing the Combination of Anticoagulation and Antiplatelet Therapy
When patients require both anticoagulation (like apixaban for atrial fibrillation) and have a history of coronary stenting, the management depends on timing:
Within the first 12 months post-DES:
- Continue triple therapy (anticoagulant + aspirin + P2Y12 inhibitor) with the duration kept as short as clinically feasible 3
- Clopidogrel is the preferred P2Y12 inhibitor when combined with anticoagulation 3
Beyond 12 months post-DES:
- Continue dual therapy with anticoagulant + aspirin 1
- The P2Y12 inhibitor can be discontinued after 12 months in most patients 1
Evidence Supporting Extended Aspirin Therapy
The DAPT trial demonstrated that continued antiplatelet therapy beyond 12 months significantly reduced stent thrombosis (0.4% vs 1.4%, p<0.001) and major adverse cardiovascular events (4.3% vs 5.9%, p<0.001). 4 While this study examined extended DAPT with both agents, the consistent guideline recommendation is that aspirin specifically should continue indefinitely. 1
The OPTIDUAL trial, though underpowered due to early termination, showed trends toward benefit with extended therapy and importantly demonstrated that aspirin monotherapy after 12 months remains standard practice. 5
Bleeding Risk Considerations
The decision to continue aspirin should only be reconsidered if the risk of life-threatening bleeding clearly outweighs the thrombotic risk. 1 For patients on triple therapy or dual therapy with anticoagulation, proton pump inhibitors should be used in those with prior gastrointestinal bleeding or increased bleeding risk. 1
When managing bleeding risk with combined anticoagulation and antiplatelet therapy:
- Use the lowest effective aspirin dose (81 mg daily preferred) 1
- Consider PPI prophylaxis for GI protection 1
- Target INR should be kept at lower therapeutic ranges when applicable 6
Common Pitfalls to Avoid
Never discontinue aspirin without cardiology consultation, even if another healthcare provider recommends stopping it. 2 Patients must be explicitly counseled that stopping antiplatelet medications can cause fatal stent thrombosis. 2, 3
Do not assume that anticoagulation alone provides adequate protection against stent thrombosis—the mechanisms of arterial thrombosis in stented vessels differ from venous or atrial thromboembolism, requiring antiplatelet therapy. 1
Avoid routine discontinuation of aspirin for minor procedures including dental work, which can typically be performed safely while continuing antiplatelet therapy. 2
Clinical Algorithm
For a patient >12 months post-DES on apixaban:
- Continue aspirin 81 mg daily indefinitely 1
- Discontinue P2Y12 inhibitor if 12 months have elapsed and no high-risk features present 1
- Continue apixaban as indicated for its primary indication (e.g., atrial fibrillation) 1
- Add PPI if history of GI bleeding or multiple bleeding risk factors 1
- Ensure cardiology follow-up and patient education about never stopping aspirin without consultation 2
The only scenario where aspirin discontinuation might be considered is if the patient experiences life-threatening bleeding that cannot be managed otherwise, and this decision must involve cardiology consultation. 1