What to do about frequent nose bleeds in an adult with atrial fibrillation and a history of cardiovascular disease, currently on apixaban (Apixaban) and Aspirin (Acetylsalicylic Acid, ASA)?

Management of Frequent Nosebleeds in a Patient on Apixaban and Aspirin for Atrial Fibrillation

You should discontinue aspirin immediately, as dual therapy with apixaban plus aspirin significantly increases bleeding risk without providing additional stroke protection in atrial fibrillation patients without a specific coronary indication. 1

Immediate Action: Stop Aspirin

• The 2020 ACC Expert Consensus and 2024 ESC Guidelines explicitly state that for patients with atrial fibrillation on oral anticoagulation who do not have acute coronary syndrome, recent PCI (<12 months), or other specific cardiovascular indications, antiplatelet therapy should be stopped. 1

• The combination of oral anticoagulation with antiplatelet agents (especially aspirin) without an adequate indication occurs frequently in clinical practice but leads to more bleeding events with no clear benefit in terms of stroke prevention or death. 1

• Bleeding events are significantly more common when antithrombotic agents are combined—the 2012 ESC Guidelines note that the risk of major bleeding with aspirin monotherapy (especially in the elderly) should be considered as being similar to oral anticoagulation alone. 1

Assess Your Patient's Cardiovascular History

You must determine if there is a legitimate indication for continuing aspirin:

• If no history of ACS and no PCI within the past 12 months: Stop aspirin immediately and continue apixaban monotherapy. 1

• If PCI was performed >12 months ago: Oral anticoagulation alone can be used long-term; stop aspirin. 1

• If PCI was 6-12 months ago: Continue single antiplatelet therapy (aspirin OR clopidogrel, not both) with oral anticoagulation until 1 year post-PCI, then transition to oral anticoagulation alone. 1

• If CABG was performed >1 year ago: Stop aspirin and continue apixaban alone. 1

• If the patient has stable ischemic heart disease or peripheral artery disease that is medically managed (no recent intervention): Antiplatelet therapy can be stopped once the oral anticoagulant is started. 1

Continue Apixaban for Stroke Prevention

• Apixaban should be continued at the appropriate dose for atrial fibrillation (5 mg twice daily for most patients, or 2.5 mg twice daily if the patient meets at least 2 of the following: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL). 2

• The ARISTOTLE trial demonstrated that apixaban reduces stroke or systemic embolism by 21% compared to warfarin, reduces all-cause mortality by 11%, and reduces major bleeding by 31%. 1, 3

• Apixaban has a 51% reduction in hemorrhagic stroke and 52% reduction in intracranial hemorrhage compared to warfarin, making it particularly appropriate for patients with bleeding concerns. 4

• Stopping apixaban increases stroke risk significantly—the FDA label warns that premature discontinuation of oral anticoagulation in the absence of adequate alternative anticoagulation increases the risk of thrombotic events. 2

Address Modifiable Bleeding Risk Factors

The HAS-BLED score should be used to identify modifiable bleeding risks that need to be addressed, not to exclude patients from oral anticoagulation therapy. 1

• Correctable risk factors for bleeding include: uncontrolled blood pressure, concomitant drugs (aspirin, NSAIDs), and alcohol use. 1

• Assess renal function (creatinine clearance) at baseline and annually, or 2-3 times per year if moderate renal impairment is present (CrCl 30-49 mL/min). 1

• Apixaban is contraindicated in severe renal impairment (CrCl <30 mL/min). 1

Local Management of Nosebleeds

• Apply local compression, ice, and supportive measures to manage the nosebleeds. 5

• Evaluate for hematoma expansion through serial physical examinations over 24-48 hours. 5

• If nosebleeds become severe, uncontrollable, or life-threatening, andexanet alfa is the preferred reversal agent for apixaban, achieving a 93% reduction in anti-Xa activity within minutes. 5

Common Pitfall to Avoid

Do not add antiplatelet treatment to anticoagulation in an attempt to prevent recurrent embolic events—the 2024 ESC Guidelines explicitly state this is not recommended and increases bleeding risk without reducing stroke risk. 1