From the Guidelines
Yes, Brilinta (ticagrelor) and Eliquis (apixaban) can be used together for patients with both NSTEMI (non-ST elevation myocardial infarction) and atrial fibrillation (AFib), but this combination requires careful management due to increased bleeding risk. This dual therapy approach is sometimes called "dual pathway inhibition" - Brilinta prevents platelet aggregation (important after a heart attack) while Eliquis prevents clot formation (crucial for AFib stroke prevention). According to the 2021 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1, ticagrelor is recommended in addition to aspirin, and maintained over 12 months unless there are contraindications or an excessive risk of bleeding.
The duration of dual therapy varies but often includes Brilinta for up to 12 months after NSTEMI, with Eliquis continued long-term for AFib. Regular monitoring for bleeding complications is essential, and patients should report any unusual bruising, bleeding gums, or blood in urine/stool immediately. The cardiologist would typically prescribe specific doses based on individual risk factors, kidney function, age, and weight.
Some key points to consider when using this combination include:
- The choice of antithrombotic regimen should be based on the selected management strategy (i.e. conservative vs. invasive) as well as the chosen revascularization modality (PCI vs. CABG) 1.
- Parenteral anticoagulation is recommended for all patients, in addition to antiplatelet treatment, at the time of diagnosis and, especially, during revascularization procedures according to both ischaemic and bleeding risks 1.
- The combination of Brilinta and Eliquis balances the need to prevent both recurrent heart attacks and stroke, but requires close medical supervision.
It is also important to note that the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes recommends using ticagrelor in preference to clopidogrel for maintenance P2Y12 treatment in patients with NSTE-ACS who undergo an early invasive or ischemia-guided strategy 1. However, the most recent and highest quality study, the 2021 ESC guidelines, should be prioritized when making a definitive recommendation.
From the Research
Non-ST-Elevation Myocardial Infarction (NSTEMI) and Atrial Fibrillation (AFib) Treatment
- The use of anticoagulants and antiplatelet therapy in patients with NSTEMI and AFib is a complex issue, with various studies suggesting different approaches 2, 3.
- Anticoagulation may be an important part of the longer-term antithrombotic strategy, especially in patients who have other existing indications for their use, such as AFib 3.
- The combination of anticoagulant and antiplatelet therapy has been shown to be effective in reducing the risk of thromboembolic events, but it also increases the risk of bleeding 2, 4.
Brilinta and Eliquis for NSTEMI and AFib
- Brilinta (ticagrelor) is an antiplatelet medication, while Eliquis (apixaban) is an anticoagulant 3.
- The use of Brilinta and Eliquis together for NSTEMI and AFib may be considered, but the decision should be based on individual patient risk factors and the balance between thromboembolic and hemorrhagic risk 4, 5.
- The HAS-BLED score is a useful tool for assessing bleeding risk in patients with AFib, and a score of 3 or higher indicates a high risk of bleeding 4, 5.
Treatment Approach
- Patients presenting with NSTEMI should be initiated on anticoagulation for the initial hospitalization period, and longer-term management should comprise triple antithrombotic therapy with an anticoagulant, aspirin, and clopidogrel for up to 1 month, followed by anticoagulant plus clopidogrel for up to 1 year, and then anticoagulant monotherapy thereafter 3.
- The treatment approach should be individualized based on patient characteristics, such as renal function, age, and comorbidities, as well as the presence of other indications for anticoagulation or antiplatelet therapy 2, 6.