What is the preferred combination of anticoagulant and antiplatelet therapy for a patient with atrial fibrillation (not valvular in origin) and a recent coronary stent, comparing Eliquis (apixaban) with Aspirin versus Eliquis (apixaban) with Plavix (clopidogrel)?

Eliquis (Apixaban) + Plavix (Clopidogrel) is Superior to Eliquis + Aspirin

For patients with atrial fibrillation and a recent coronary stent, the preferred regimen is Eliquis (apixaban) plus Plavix (clopidogrel) without aspirin, as this dual therapy significantly reduces bleeding risk by approximately 50% compared to triple therapy while maintaining equivalent protection against ischemic events. 1, 2, 3

Immediate Post-PCI Management

Stop aspirin immediately after hospital discharge (within 1 week of PCI) and continue only Eliquis plus Plavix. 1, 2, 4

• Brief triple therapy (Eliquis + aspirin + Plavix) may be used only during the immediate peri-PCI hospitalization period, with a maximum duration of 1 week for most patients 1, 4
• Triple therapy can extend up to 1 month only in highly selected patients at exceptionally high thrombotic risk (complex lesions, left main stenting, multiple stents) AND low bleeding risk 1
• The most common preventable error is continuing triple therapy beyond the acute post-PCI period, which increases major bleeding by 40-50% without proportionate benefit 2

Duration of Dual Therapy (Eliquis + Plavix)

The duration depends on your indication for PCI:

For Acute Coronary Syndrome (ACS):

• Continue Eliquis + Plavix for 6-12 months post-PCI 1, 4
• After 12 months, discontinue Plavix and continue Eliquis alone indefinitely 1

For Stable Coronary Disease:

• Continue Eliquis + Plavix for 6 months post-PCI 1, 4
• After 6 months, discontinue Plavix and continue Eliquis alone indefinitely 1

Evidence Supporting Plavix Over Aspirin

The AUGUSTUS trial (n=4,614 patients) definitively demonstrated that aspirin doubled total bleeding events (rate ratio 2.14) without reducing ischemic events when added to apixaban plus a P2Y12 inhibitor 3

Key findings from major trials comparing dual vs. triple therapy:

• AUGUSTUS: Apixaban + P2Y12 inhibitor without aspirin reduced major/clinically relevant bleeding by 31% compared to triple therapy (10.5% vs 14.7%), with no increase in death, MI, stroke, or stent thrombosis 1, 3
• PIONEER AF-PCI: Rivaroxaban + P2Y12 inhibitor reduced bleeding by 41% vs. triple therapy 1
• RE-DUAL PCI: Dabigatran + P2Y12 inhibitor reduced bleeding by 48% vs. triple therapy 1

Medication Selection Specifics

Use clopidogrel (Plavix) as the P2Y12 inhibitor, not prasugrel or ticagrelor, as the more potent agents substantially increase bleeding risk when combined with anticoagulation 1, 2, 4

Use apixaban (Eliquis) at standard dosing (5 mg twice daily) unless dose-reduction criteria are met (any 2 of: age ≥80 years, weight ≤60 kg, creatinine ≥1.5 mg/dL) 1

• DOACs like Eliquis are strongly preferred over warfarin due to 50% lower intracranial hemorrhage risk 1, 2

Bleeding Risk Mitigation Strategies

Implement these measures for all patients on dual antithrombotic therapy:

• Prescribe proton pump inhibitors for gastrointestinal protection 2, 5
• Optimize blood pressure control (target <130/80 mmHg) 2, 5
• Avoid NSAIDs and other medications that increase bleeding risk 2, 5
• Monitor renal function and adjust Eliquis dosing accordingly 2, 5

Critical Pitfalls to Avoid

1. Never continue triple therapy beyond 1 month - this is the single most common error leading to preventable major bleeding 2
2. Never add antiplatelet therapy to anticoagulation for stroke prevention alone - anticoagulation is superior and antiplatelet therapy only adds bleeding risk 2
3. Never use prasugrel or ticagrelor in combination with anticoagulation unless absolutely necessary (e.g., documented stent thrombosis on clopidogrel) 1
4. Never use low-dose rivaroxaban (2.5 mg twice daily) for stroke prevention in AF - this dose is not approved for this indication 1