Management of Antiplatelet Therapy in Patients with Atrial Fibrillation and History of Cerebrovascular Accident

Primary Recommendation

The American College of Cardiology recommends stopping all antiplatelet therapy and treating with apixaban alone for patients with a history of cerebrovascular accident who develop atrial fibrillation requiring oral anticoagulation, once it is considered safe from the perspective of hemorrhagic transformation, typically between 2 and 14 days following an acute stroke event 1, 2, 3
For patients with an "old CVA", antiplatelet agents can be stopped immediately and apixaban monotherapy can be continued 1

Apixaban alone provides adequate stroke prevention for atrial fibrillation, making additional antiplatelet therapy unnecessary and harmful in patients without recent acute coronary syndrome or recent coronary intervention 1, 3
The 2020 American College of Cardiology Expert Consensus Decision Pathway recommends stopping all antiplatelet therapy and treating with an oral anticoagulant alone (DOAC preferred) for patients on antiplatelet therapy for prior TIA or cerebrovascular accident who develop atrial fibrillation requiring oral anticoagulation 1, 2, 3

If the patient has recent acute coronary syndrome (<12 months), stop aspirin but continue clopidogrel with apixaban until 12 months post-ACS, then transition to apixaban alone 1, 4
If the patient has recent PCI with stenting (<12 months), stop aspirin but continue clopidogrel with apixaban until 12 months post-PCI, then transition to apixaban alone 1, 2
If the patient has none of the above conditions, stop both aspirin and clopidogrel immediately and continue apixaban monotherapy 1, 3

For patients with concurrent coronary disease, the American College of Cardiology recommends continuing clopidogrel with apixaban for a specified duration, then transitioning to apixaban alone 1, 2, 4, 5
The American College of Cardiology also recommends addressing modifiable bleeding risk factors, such as using proton pump inhibitors for gastrointestinal protection, optimizing blood pressure control, avoiding NSAIDs, and monitoring renal function 3