Management of Antithrombotic Therapy in Elderly Patients with Suspected Acute Coronary Syndrome

Rationale for Avoiding Aspirin in Elderly Patients

The European Society of Cardiology guidelines recommend careful consideration of antithrombotic regimens in patients already on oral anticoagulation, with preference for avoiding triple therapy (oral anticoagulant plus dual antiplatelet therapy) whenever possible 1
Advanced age (94 years) is a major risk factor for bleeding complications, making the risk-benefit ratio of adding aspirin to apixaban even less favorable 2

For patients with suspected acute coronary syndrome who are already on apixaban, the European Society of Cardiology recommends continuing the apixaban at the current dose 3
The American College of Cardiology and American Heart Association guidelines emphasize that while aspirin is recommended for ACS patients in general, this recommendation must be balanced against bleeding risk, which is particularly high in elderly patients on oral anticoagulation 6

In patients ≥80 years old, the bleeding risk with antithrombotic therapy is substantially higher, requiring careful consideration of the necessity of any additional antithrombotic agent 2
For elderly patients on apixaban with suspected ACS, the priority should be to confirm the diagnosis before making changes to the antithrombotic regimen, according to the American Heart Association 7
The duration of dual therapy should be minimized to reduce bleeding risk, as recommended by the European Society of Cardiology and the American Heart Association 3, 5