Should aspirin (acetylsalicylic acid) 81mg be continued in a patient on Eliquis (apixaban) with a history of myocardial infarction (MI)?

From the Guidelines

If you have a history of myocardial infarction (MI) and are currently taking Eliquis (apixaban), you should consider discontinuing aspirin 81mg, as the combination may not be necessary and could increase bleeding risk, according to the most recent guidelines 1.

Key Considerations

• The decision to continue or discontinue aspirin depends on your specific cardiovascular risk factors, time since your MI, presence of coronary stents, and your individual bleeding risk.
• Eliquis alone provides effective anticoagulation for many patients, and the added benefit of aspirin must be weighed against the approximately doubled risk of bleeding when these medications are combined.
• If it has been less than 12 months since the MI, the recommendation is to stop aspirin and continue the P2Y12 inhibitor (with preference given to clopidogrel) and start an anticoagulant (with preference given to a direct oral anticoagulant (DOAC) like Eliquis) 1.
• If it has been more than 12 months since the MI, antiplatelet therapy may be stopped, and most patients can be treated with an anticoagulant alone 1.

Personalized Medical Decision

This is a personalized medical decision that should be made with your cardiologist who understands your complete medical history. Your doctor may recommend continuing both medications temporarily if you've had a recent MI or complex coronary intervention.

Evidence-Based Recommendation

The 2021 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease recommends discontinuing aspirin in most patients with a history of MI who are taking a DOAC like Eliquis 1.

Bleeding Risk Consideration

The risk of bleeding should be carefully considered when making this decision, as the combination of aspirin and Eliquis may increase the risk of bleeding 1.

Conclusion Not Needed, Decision Made

Discontinuing aspirin 81mg is recommended for most patients with a history of MI who are taking Eliquis, unless there are specific reasons to continue antiplatelet therapy, such as a high thrombotic risk and low bleeding risk 1.

From the FDA Drug Label

In ARISTOTLE, the results for the primary efficacy endpoint were generally consistent across most major subgroups including weight, CHADS2 score (a scale from 0 to 6 used to predict risk of stroke in patients with AF, with higher scores predicting greater risk), prior warfarin use, level of renal impairment, geographic region, and aspirin use at randomization (Figure 5)

The decision to continue aspirin 81mg in a patient on Eliquis (apixaban) with a history of MI is not directly addressed in the provided drug label. However, the label does mention that the results of the ARISTOTLE study were consistent across subgroups, including those with aspirin use at randomization.

• The label does not provide explicit guidance on the use of aspirin in patients with a history of MI who are taking Eliquis.
• Aspirin use is mentioned as a subgroup in the ARISTOTLE study, but the label does not specify the outcomes for this subgroup.
• Given the lack of direct information, a conservative clinical decision would be to consult additional resources or guidelines for guidance on the use of aspirin in this patient population 2.

From the Research

Aspirin and Eliquis Use in Patients with History of MI

• The use of aspirin 81mg in patients with a history of myocardial infarction (MI) who are also on Eliquis is not directly addressed in the provided studies.
• However, the studies suggest that patients with a history of MI are at increased risk for recurrent cardiovascular events 3, 4, 5.
• The use of antiplatelet therapy, such as aspirin, is a common practice in patients with a history of MI to reduce the risk of recurrent cardiovascular events.
• The study by 3 found that the implementation of guideline-recommended therapies, including antiplatelet therapy, has improved over time, with the highest-risk groups demonstrating the greatest benefit in outcomes.
• Another study by 4 found that the risk of major adverse cardiovascular events (MACE) remains elevated among post-MI patients after the first year, suggesting that long-term management and monitoring are necessary.

Interaction between Aspirin and Eliquis

• There is no direct evidence in the provided studies on the interaction between aspirin 81mg and Eliquis in patients with a history of MI.
• However, the study by 6 found that the use of proton pump inhibitors (PPIs) in patients taking aspirin and clopidogrel increased the rates of major adverse cardiovascular events, stent thrombosis, and revascularization.
• Another study by 7 found that the use of PPIs in aspirin-treated patients with first-time MI was associated with an increased risk of adverse cardiovascular events.

Clinical Implications

• Patients with a history of MI who are on Eliquis should be closely monitored for recurrent cardiovascular events 4, 5.
• The use of aspirin 81mg in these patients may be considered as part of a comprehensive management plan to reduce the risk of recurrent cardiovascular events 3.
• However, the decision to continue or discontinue aspirin 81mg in patients on Eliquis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.