In a patient with coronary artery disease on aspirin (acetylsalicylic acid) prescribed by cardiology, should aspirin be stopped when starting apixaban (Eliquis)?

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Should Aspirin Be Stopped When Starting Eliquis in CAD Patients?

In patients with stable coronary artery disease on aspirin who need to start apixaban (Eliquis) for atrial fibrillation, aspirin should be stopped immediately unless the patient had PCI within the past 12 months or acute coronary syndrome within the past 12 months. 1

Decision Algorithm Based on Timing of Coronary Events

Stable CAD Without Recent Events (>12 months since any intervention)

  • Stop aspirin immediately and continue Eliquis alone. 1
  • The 2024 ESC Guidelines give a Class III recommendation (meaning "do not do this") against adding any antiplatelet agent to oral anticoagulation for stroke prevention in atrial fibrillation patients. 1
  • Adequate anticoagulation with apixaban provides superior protection compared to aspirin in chronic stable angina, making the combination unnecessary and harmful. 1

Recent PCI (Within Past 12 Months)

For patients 1-6 months post-PCI:

  • Stop aspirin immediately 1
  • Continue dual therapy with Eliquis + clopidogrel (not aspirin) 1, 2
  • Clopidogrel is specifically preferred over prasugrel or ticagrelor when combined with apixaban due to lower bleeding risk 1, 2

For patients 6-12 months post-PCI:

  • Stop aspirin 1
  • Continue either clopidogrel or aspirin with Eliquis (though clopidogrel is preferred) 1

For patients >12 months post-PCI:

  • Stop all antiplatelet therapy 1
  • Continue Eliquis alone 1

Recent Acute Coronary Syndrome (Within Past 12 Months)

For patients <12 months since ACS:

  • Stop aspirin 1
  • Continue Eliquis + clopidogrel 1, 2

For patients >12 months since ACS:

  • Stop all antiplatelet therapy 1
  • Continue Eliquis alone 1

Why Aspirin Should Be Stopped: The Evidence

Bleeding Risk Without Ischemic Benefit

  • Combining apixaban with aspirin markedly raises bleeding risk in patients with stable angina without providing additional protection against ischemic outcomes. 1
  • The ACC/AHA guidelines explicitly state that concomitant use of oral anticoagulants (including DOACs like Eliquis) and aspirin increases the risk of major bleeding, especially gastrointestinal bleeding. 1
  • The combination significantly increases bleeding risk without providing meaningful additional protection against ischemic events. 1

Triple Therapy Should Be Extremely Limited

  • If triple therapy (Eliquis + aspirin + clopidogrel) is used at all, it should be limited to a maximum of 30 days and reserved only for patients at the highest thrombotic risk. 1, 2
  • Triple therapy should be used only during the immediate peri-PCI hospitalization period, with a maximum duration of 1 week for most patients. 2
  • The 2022 guideline on drug interactions reinforces that triple antithrombotic therapy should not exceed 30 days. 1

Critical Pitfalls to Avoid

Most Common Error

  • Continuing triple therapy beyond 1 month is the single most common error leading to preventable major bleeding. 2
  • Do not add antiplatelet therapy to anticoagulation for stroke prevention alone. 2

Medication Selection Errors

  • Do not use prasugrel or ticagrelor in combination with anticoagulation unless absolutely necessary, as these substantially increase bleeding risk compared to clopidogrel. 2

Bleeding Risk Mitigation Strategies

When any antithrombotic therapy is continued, implement these protective measures:

  • Prescribe proton pump inhibitors for gastrointestinal protection 1, 2
  • Optimize blood pressure control to target <130/80 mmHg 2
  • Avoid NSAIDs and other medications that increase bleeding risk 1, 2
  • Monitor renal function and adjust Eliquis dosing accordingly 1, 2

Coordination With Cardiology

Since cardiology initiated the aspirin for CAD, communication is important but the evidence is clear:

  • The decision to stop aspirin in stable CAD patients starting anticoagulation is supported by the highest-level guidelines (2024 ESC Class III recommendation). 1
  • Apixaban monotherapy provides adequate protection for both stroke prevention and chronic stable CAD when no recent coronary events have occurred. 1
  • The AVERROES trial demonstrated that apixaban monotherapy is superior to aspirin for stroke prevention in atrial fibrillation, with comparable rates of major bleeding. 1

References

1
Guideline

Aspirin, Apixaban, and Antiplatelet Management in Atrial Fibrillation with Chronic Angina

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Dual Antithrombotic Therapy for Atrial Fibrillation and Coronary Stent Patients

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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