Should Aspirin Be Added to Apixaban After CVA?
No, aspirin should NOT be added to apixaban for a patient with a history of CVA unless there is a specific concurrent indication such as recent acute coronary syndrome or percutaneous coronary intervention. 1
Primary Recommendation
For patients with a history of stroke or TIA on apixaban for stroke prevention, apixaban monotherapy is the appropriate treatment without adding aspirin. 1 The combination significantly increases bleeding risk without providing additional thromboembolic protection in this population. 1
Evidence Supporting Apixaban Monotherapy After CVA
Efficacy in Secondary Stroke Prevention
In patients with subclinical atrial fibrillation and prior stroke/TIA, apixaban reduced stroke or systemic embolism to 1.20% per year compared to 3.14% per year with aspirin alone (HR 0.40,95% CI 0.17-0.95). 2
The absolute risk reduction for stroke/systemic embolism at 3.5 years was 7% in patients with prior stroke/TIA, compared to only 1% in those without prior stroke. 2
This demonstrates that patients with prior CVA derive substantial benefit from apixaban alone, making additional aspirin unnecessary. 2
Safety Concerns with Combination Therapy
Adding aspirin to apixaban increases major bleeding risk substantially. 1 In the AUGUSTUS trial, aspirin increased major or clinically relevant non-major bleeding, particularly in patients without prior stroke/TIA. 3
Major bleeding occurred at 2.26% per year with apixaban versus 1.16% per year with aspirin in patients with prior stroke/TIA, with an absolute risk increase of 3% at 3.5 years when using apixaban. 2
The bleeding risk from combination therapy outweighs any theoretical benefit in stroke prevention for most patients. 1
Clinical Context: When Aspirin MIGHT Be Added
Recent Acute Coronary Syndrome or PCI
The only scenario where aspirin should be added to apixaban in a CVA patient is if they have concurrent recent coronary intervention: 1
- <6 months post-PCI: Stop aspirin and continue P2Y12 inhibitor (clopidogrel preferred) plus apixaban. 1
- 6-12 months post-PCI: Continue either aspirin OR clopidogrel (not both) plus apixaban. 1
- >12 months post-PCI: Stop all antiplatelet therapy and continue apixaban alone. 1
Stable Coronary Disease
For medically managed stable ischemic heart disease or peripheral artery disease, stop aspirin once apixaban is established. 1
Anticoagulation alone is preferred over combination with aspirin in patients with stable coronary disease. 4
Guideline Support for Avoiding Combination Therapy
The American Heart Association/American Stroke Association guidelines state there is no evidence that combining anticoagulation with an antiplatelet agent reduces the risk of stroke or MI compared with anticoagulant therapy alone in atrial fibrillation patients, but there is clear evidence of increased bleeding risk. 5
Therefore, addition of aspirin to anticoagulation therapy should be avoided in AF patients with prior stroke. 5
Critical Safety Considerations
Avoid combination therapy in patients with: 1
- NSAID use
- Active cancer
- History of gastrointestinal bleeding
- Advanced age (bleeding risk increases significantly)
Common Pitfalls to Avoid
Do not continue aspirin "just in case" after starting apixaban for stroke prevention—this outdated practice increases bleeding without benefit. 1
Do not assume all CVA patients need dual therapy—only those with concurrent acute coronary syndromes or recent PCI require temporary dual antiplatelet/anticoagulant therapy. 1, 3
Do not confuse subclinical atrial fibrillation data with clinical stroke patients—while the ARTESiA trial showed benefit of apixaban over aspirin in subclinical AF with prior stroke, this supports using apixaban INSTEAD of aspirin, not in addition to it. 2