How long should aspirin be continued after Coronary Artery Bypass Grafting (CABG) in patients on Eliquis (apixaban)?

Duration of Aspirin After CABG in Patients on Eliquis (Apixaban)

For patients on Eliquis (apixaban) who have undergone CABG, aspirin should be continued for up to 12 months post-surgery, then discontinued, with the patient maintained on apixaban monotherapy thereafter. 1

Time-Based Algorithm for Aspirin Duration

Less Than 12 Months Post-CABG

• Continue aspirin (<100 mg/day) in combination with apixaban until reaching the 12-month mark post-CABG 1
• This dual therapy approach balances the proven benefit of aspirin for vein graft patency during the critical first postoperative year against the increased bleeding risk when combined with oral anticoagulation 1
• Aspirin therapy after CABG improves vein graft patency particularly during the first postoperative year and reduces major adverse cardiovascular events 1

Greater Than 12 Months Post-CABG

• Discontinue aspirin completely and continue apixaban monotherapy alone 1
• The ACC Expert Consensus explicitly states: "We recommend continuing aspirin (<100 mg/day) if <1 year post-CABG surgery and stopping aspirin if >1 year post-CABG surgery" 1
• Beyond 12 months, the marginal benefit of aspirin for graft patency diminishes while bleeding risk from combination therapy remains elevated 1

Critical Context: Why This Differs from Standard CABG Management

Standard CABG Without Anticoagulation

• Aspirin monotherapy is typically continued indefinitely after CABG to maintain graft patency 1
• The 2016 ACC/AHA guidelines recommend daily aspirin 81 mg (range 75-100 mg) as a Class I recommendation for all CABG patients 1

Modified Approach When Oral Anticoagulation Required

• The presence of oral anticoagulation fundamentally changes the risk-benefit calculation 1
• The 2016 guidelines specifically note that oral anticoagulant use represents a "high bleeding risk" scenario where extended dual antiplatelet therapy becomes less reasonable 1
• Combination of aspirin with warfarin (and by extension, DOACs like apixaban) significantly increases bleeding risk without proportional ischemic benefit beyond 12 months post-CABG 1

Dosing Specifications

Aspirin Dosing During the First Year

• Use low-dose aspirin 81 mg daily (acceptable range 75-100 mg) 1
• Higher doses (>100 mg) increase bleeding risk without improving efficacy when combined with oral anticoagulation 1

Apixaban Dosing

• Standard dose: 5 mg twice daily 2
• Reduced dose: 2.5 mg twice daily if patient meets ANY TWO of the following criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 2

Special Circumstances That May Modify This Approach

If Recent ACS Preceded CABG

• If CABG was performed for acute coronary syndrome, consider whether dual antiplatelet therapy (DAPT) was initiated pre-operatively 1
• In such cases, the P2Y12 inhibitor (preferably clopidogrel, not aspirin) should be combined with apixaban, and aspirin should be stopped earlier 1
• Complete 12 months of antithrombotic therapy from the time of ACS, not from CABG date 1

High Thrombotic Risk Features

• Selected patients with particularly high thrombotic risk (complex coronary anatomy, multiple grafts, poor target vessels) and low bleeding risk may warrant continuation of aspirin beyond 12 months at physician discretion 1
• However, this represents a minority exception rather than standard practice 1

High Bleeding Risk Considerations

• Patients with elevated bleeding risk (HAS-BLED score ≥3) may warrant earlier discontinuation of aspirin (potentially at 6 months rather than 12 months) 1
• Formal bleeding risk assessment should be performed, but should not result in withholding necessary anticoagulation 2

Common Pitfalls and How to Avoid Them

Pitfall #1: Continuing Aspirin Indefinitely

• Avoid: Many clinicians reflexively continue aspirin indefinitely after CABG based on standard guidelines that don't account for concurrent oral anticoagulation 1
• Solution: Actively reassess at 12 months post-CABG and discontinue aspirin when patient is on therapeutic anticoagulation 1

Pitfall #2: Stopping Aspirin Too Early

• Avoid: Discontinuing aspirin immediately when starting apixaban in the early post-CABG period 1
• Solution: Maintain aspirin for the full 12-month period to optimize vein graft patency during the critical first year 1, 3

Pitfall #3: Using Excessive Aspirin Doses

• Avoid: Prescribing aspirin doses >100 mg daily when combined with oral anticoagulation 1
• Solution: Use low-dose aspirin 81 mg daily to minimize bleeding risk while maintaining antiplatelet effect 1

Pitfall #4: Failing to Consider the Indication for Anticoagulation

• Avoid: Treating all patients on apixaban identically without considering whether indication is atrial fibrillation, venous thromboembolism, or other 1
• Solution: The 12-month aspirin duration applies regardless of anticoagulation indication, but ensure the anticoagulation itself is appropriately indicated and dosed 1, 2

Evidence Quality and Strength

The recommendations for stopping aspirin at 12 months post-CABG in patients on oral anticoagulation come from high-quality 2021 ACC Expert Consensus Decision Pathways 1, which represent the most recent and directly applicable guidance for this specific clinical scenario. These supersede older general CABG guidelines that did not address the combination therapy situation 1.

The 2025 TACSI trial 4 demonstrated that adding ticagrelor to aspirin after CABG for acute coronary syndrome did not reduce cardiovascular events but significantly increased major bleeding (hazard ratio 2.50), reinforcing the principle that combination antiplatelet/anticoagulant therapy beyond necessary durations increases harm without benefit.