Yes, you should withhold both ecosprin (aspirin) and clopilet (clopidogrel) in this patient with old CVA who has now developed atrial fibrillation and is started on apixaban.
Primary Recommendation
For patients with a history of cerebrovascular accident who develop atrial fibrillation requiring oral anticoagulation, stop all antiplatelet therapy and treat with apixaban alone. 1 This recommendation applies once it is considered safe from the perspective of hemorrhagic transformation, typically between 2 and 14 days following an acute stroke event. 1, 2 Since your patient has an "old CVA" (not acute), you can stop both antiplatelet agents immediately and continue apixaban monotherapy. 1
Rationale for Stopping Dual Antiplatelet Therapy
Bleeding Risk Without Ischemic Benefit
Triple therapy (oral anticoagulant + aspirin + clopidogrel) significantly increases bleeding risk without providing additional stroke prevention benefit in atrial fibrillation patients. 3 The AUGUSTUS trial demonstrated that aspirin doubled total bleeding risk (rate ratio 2.14,95% CI 1.75-2.60) compared with placebo when added to oral anticoagulation and a P2Y12 inhibitor, without reducing ischemic events. 3
Apixaban alone provides adequate stroke prevention for atrial fibrillation, making additional antiplatelet therapy unnecessary and harmful in patients without recent acute coronary syndrome or recent coronary intervention. 1, 2
Guideline-Based Approach
The 2020 American College of Cardiology Expert Consensus Decision Pathway explicitly states that for patients on antiplatelet therapy for prior TIA or cerebrovascular accident who develop atrial fibrillation requiring oral anticoagulation, the pathway recommends stopping all antiplatelet therapy and treating with an oral anticoagulant alone (DOAC preferred). 1, 2
This recommendation is categorical and does not require continuation of antiplatelet agents unless there are specific concurrent indications such as recent acute coronary syndrome (<12 months) or recent coronary stenting (<12 months). 1
Clinical Algorithm for Your Patient
Step 1: Assess Timing of CVA
- If the CVA occurred >14 days ago: Stop both aspirin and clopidogrel immediately. 1, 2
- If the CVA occurred <14 days ago: Assess for hemorrhagic transformation risk before stopping antiplatelet agents, with earlier initiation of anticoagulation alone for smaller infarcts and later initiation for larger infarcts. 2
Step 2: Evaluate for Concurrent Coronary Disease
You must determine if your patient has any of the following:
Recent acute coronary syndrome (<12 months): If yes, stop aspirin but continue clopidogrel with apixaban until 12 months post-ACS, then transition to apixaban alone. 1
Recent PCI with stenting (<12 months): If yes, stop aspirin but continue clopidogrel with apixaban until 12 months post-PCI, then transition to apixaban alone. 1
Recent carotid stenting (1-3 months): If yes, stop aspirin but continue clopidogrel with apixaban until the standard duration of dual antiplatelet therapy after carotid stenting has ended (usually 1-3 months). 1
None of the above: Stop both aspirin and clopidogrel immediately and continue apixaban monotherapy. 1, 2
Step 3: Confirm Apixaban Dosing
- Standard dose: 5 mg twice daily for most patients. 4
- Reduced dose: 2.5 mg twice daily if patient has at least 2 of the following: age ≥80 years, body weight ≤60 kg, serum creatinine ≥1.5 mg/dL. 4
Evidence Strength and Nuances
Why Oral Anticoagulation Alone is Superior
The ACTIVE W trial demonstrated that oral anticoagulation therapy is superior to clopidogrel plus aspirin for prevention of vascular events in patients with atrial fibrillation at high risk of stroke (relative risk 1.44,95% CI 1.18-1.76, p=0.0003). 5
Apixaban specifically has been shown to reduce total bleeding risk compared with vitamin K antagonists (rate ratio 0.66,95% CI 0.55-0.80) while maintaining similar rates of ischemic events. 3
Special Consideration for Stroke Patients
The AUGUSTUS post-hoc analysis of patients with prior stroke/TIA/thromboembolism showed that apixaban plus a P2Y12 inhibitor without aspirin is appropriate for the majority of patients with atrial fibrillation and recent ACS/PCI, regardless of prior stroke status. 6
However, this applies to patients with concurrent ACS/PCI. For patients with stroke history but no recent ACS/PCI (which appears to be your patient's situation), anticoagulation monotherapy is the standard. 1, 2
Critical Pitfalls to Avoid
Do Not Continue "Just to Be Safe"
- Continuing antiplatelet therapy "for extra protection" actually increases harm through bleeding without reducing stroke risk when adequate anticoagulation is provided. 3 This is a common error driven by fear of recurrent stroke, but the evidence clearly shows net harm from this approach.
Do Not Reduce Apixaban Dose Unnecessarily
- Only reduce apixaban dose if the patient meets the specific criteria outlined above (2 of 3: age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL). 4 Empiric dose reduction increases stroke risk without proven bleeding benefit. 2
Address Modifiable Bleeding Risk Factors
- Use proton pump inhibitors for gastrointestinal protection. 2
- Optimize blood pressure control. 2
- Avoid NSAIDs and other medications that increase bleeding risk. 2
- Monitor renal function and adjust DOAC dosing accordingly. 2
Timing Matters for Acute Stroke
- If this were an acute stroke (which it is not based on your description of "old CVA"), you would need to wait 2-14 days before initiating anticoagulation to minimize hemorrhagic transformation risk. 1, 2 For an old stroke, this concern does not apply.
Bottom Line for Your Patient
Stop both ecosprin and clopilet immediately and continue apixaban monotherapy at the appropriate dose. 1, 2 This approach maximizes stroke prevention while minimizing bleeding risk, which directly improves both morbidity and mortality outcomes compared to continuing unnecessary antiplatelet therapy. 3, 5