Does an elderly male patient with a history of atrial fibrillation (A-fib) and cerebrovascular accident (CVA) on Eliquis (apixaban) 5 mg twice daily require additional aspirin for stroke prevention?

Discontinue Aspirin Immediately in This Patient

This elderly male patient with atrial fibrillation and prior stroke on Eliquis 5 mg twice daily does NOT need aspirin and should have it discontinued immediately. Adding aspirin to therapeutic anticoagulation provides no additional stroke protection but significantly increases bleeding risk, particularly intracranial hemorrhage in elderly patients 1, 2.

Why Aspirin Should Be Discontinued

Evidence Against Combination Therapy

• Combining aspirin with oral anticoagulation does not reduce stroke or myocardial infarction risk compared to anticoagulation alone in atrial fibrillation patients, but clearly increases major bleeding risk 1, 2
• The American Heart Association explicitly states that aspirin and other antiplatelet agents should be discontinued once oral anticoagulation is initiated, as the combination increases bleeding risk without providing additional benefit 2
• In elderly patients specifically, combining aspirin with oral anticoagulation at therapeutic intensities may accentuate intracranial hemorrhage 1

This Patient's Stroke Risk is Already Adequately Addressed

• With a prior CVA, this patient has a CHA₂DS₂-VASc score of at least 2 (stroke alone = 2 points), placing him at high risk requiring oral anticoagulation 2
• Eliquis (apixaban) 5 mg twice daily provides superior stroke prevention compared to warfarin, with 21% relative risk reduction in stroke/systemic embolism and 51% reduction in hemorrhagic stroke 2
• Oral anticoagulation reduces stroke risk by 62% in atrial fibrillation patients, while aspirin provides only 22% risk reduction 2, 3

The Plavix (Clopidogrel) Situation

Plavix Should Also Be Discontinued

• This patient is on Plavix for "CVA with right-sided weakness," but this is inappropriate long-term management for cardioembolic stroke from atrial fibrillation 2
• The American College of Chest Physicians strongly recommends against antiplatelet therapy (including clopidogrel) when oral anticoagulation is indicated for atrial fibrillation patients with prior stroke 2
• Antiplatelet therapy alone is explicitly NOT recommended for cardioembolic stroke prevention in atrial fibrillation 2

When Dual Antiplatelet Therapy Might Have Been Considered

• Clopidogrel plus aspirin offers more protection than aspirin alone in atrial fibrillation patients deemed "unsuitable for anticoagulation," but with increased major bleeding (2.0% vs 1.3% per year) 1
• However, this patient is clearly suitable for anticoagulation (already on Eliquis) and has no documented contraindication 2

Clinical Action Plan

Immediate Medication Changes

1. Discontinue aspirin 81 mg immediately - no stroke prevention benefit when combined with Eliquis, only increased bleeding risk 1, 2
2. Discontinue Plavix (clopidogrel) - inappropriate for cardioembolic stroke prevention when therapeutic anticoagulation is available 2
3. Continue Eliquis 5 mg twice daily - this is the appropriate monotherapy for stroke prevention in this patient 2

Verify Eliquis Dosing is Appropriate

• Standard dose is 5 mg twice daily 2
• Dose reduction to 2.5 mg twice daily is indicated ONLY if patient meets at least 2 of 3 criteria: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 2
• Do not arbitrarily reduce the dose, as this leads to inadequate stroke prevention 2

Common Pitfalls to Avoid

The "Triple Therapy" Misconception

• There is no indication for triple therapy (anticoagulation + aspirin + clopidogrel) in this patient who has no acute coronary syndrome or recent stenting 4
• Triple therapy is reserved only for the early period following acute coronary syndrome or stenting in atrial fibrillation patients, and even then should be limited to the shortest duration possible 4

The "Aspirin is Safer" Fallacy

• Well-managed anticoagulation (Eliquis in this case) has similar or lower bleeding risk compared to aspirin, especially in preventing the most devastating bleeding complication—intracranial hemorrhage 2, 3
• Aspirin is rarely the right choice for stroke prevention in atrial fibrillation 3

Monitoring Considerations

• Focus on modifiable bleeding risk factors: ensure blood pressure is well-controlled, avoid NSAIDs, minimize alcohol consumption 2
• The patient's bradycardia (53 bpm) and fatigue after metoprolol discontinuation should be monitored, but this does not change anticoagulation strategy 2
• No routine laboratory monitoring is required for Eliquis, unlike warfarin 2

Bottom Line

Discontinue both aspirin and Plavix. Continue Eliquis 5 mg twice daily as monotherapy. This provides optimal stroke prevention with the lowest bleeding risk for this elderly patient with atrial fibrillation and prior stroke 2.