Should aspirin be given to a patient with atrial fibrillation on Xarelto (rivaroxaban) who complains of chest pain?

From the Guidelines

No, aspirin should not be given to a patient on Xarelto (rivaroxaban) who has atrial fibrillation and is experiencing chest pain. Combining Xarelto with aspirin significantly increases the risk of bleeding complications without providing additional benefit for most patients with atrial fibrillation. Instead, the patient should be evaluated immediately for the cause of chest pain, which could indicate a cardiac event requiring different management. The appropriate approach would be to perform an ECG, cardiac enzyme tests, and other relevant assessments to determine if the chest pain is due to acute coronary syndrome, pulmonary embolism, or another cause. Xarelto is an anticoagulant that prevents clot formation by inhibiting Factor Xa in the coagulation cascade, while aspirin is an antiplatelet agent that works through a different mechanism. Using both simultaneously creates a dangerous "double anticoagulation" effect. If the patient is diagnosed with an acute coronary syndrome, the management would need to be carefully coordinated between cardiology and hematology to balance thrombotic and bleeding risks, as suggested by the 2018 update on antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention 1.

Key Considerations

• The patient's current anticoagulation therapy with Xarelto should be taken into account when assessing the risk of bleeding complications.
• The 2024 American Heart Association and American Red Cross guidelines for first aid emphasize the importance of immediate evaluation and management of chest pain, but do not specifically address the use of aspirin in patients on anticoagulant therapy like Xarelto 1.
• The 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care recommend aspirin for persons with chest pain due to suspected myocardial infarction, but also note the importance of considering the individual's risk of bleeding and other contraindications 1.
• In the absence of specific guidance on the use of aspirin in patients on Xarelto, the most recent and highest quality evidence suggests that the risks of bleeding complications outweigh any potential benefits of adding aspirin to the patient's treatment regimen.

Management Approach

• Immediate evaluation of the patient's chest pain to determine the underlying cause.
• Performance of an ECG, cardiac enzyme tests, and other relevant assessments to determine if the chest pain is due to acute coronary syndrome, pulmonary embolism, or another cause.
• Careful coordination of management between cardiology and hematology to balance thrombotic and bleeding risks if the patient is diagnosed with an acute coronary syndrome.
• Consideration of the patient's individual risk factors and contraindications when determining the best course of treatment.

From the FDA Drug Label

XARELTO is used with low dose aspirin to: reduce the risk of serious heart problems, heart attack and stroke in adults with coronary artery disease (a condition where the blood supply to the heart is reduced or blocked) You may have a higher risk of bleeding if you take XARELTO and take other medicines that increase your risk of bleeding, including: aspirin or aspirin containing products

The patient is on Xarelto for atrial fibrillation, not coronary artery disease. Aspirin is not recommended for patients on XARELTO for atrial fibrillation, as it may increase the risk of bleeding. In the context of the patient complaining of chest pain, the decision to give aspirin should be made with caution, considering the increased risk of bleeding associated with concomitant use of XARELTO and aspirin 2.

From the Research

Patient on Xarelto for Atrial Fibrillation with Chest Pain

• The patient is currently taking Xarelto (rivaroxaban) for atrial fibrillation and presents with chest pain, raising the question of whether aspirin should be given.
• According to the study 3, rivaroxaban has been approved for use in patients with a recent acute coronary syndrome (ACS) in combination with aspirin alone or aspirin plus either clopidogrel or ticlopidine.
• The ATLAS ACS 2-TIMI 51 trial, cited in 3, showed that rivaroxaban 2.5 mg twice daily, co-administered with aspirin or aspirin plus either clopidogrel or ticlopidine, reduced the rate of the primary composite endpoint, which included death from cardiovascular causes, myocardial infarction, or stroke.
• However, the study 4 notes that the combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding, and the safety implications of rivaroxaban used in combination with aspirin plus either ticagrelor or prasugrel are unknown.
• The North American Consensus Statement, cited in 5, recommends that in patients with atrial fibrillation undergoing PCI, a non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice, and dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period.
• The study 6 suggests that in patients with atrial fibrillation and recent acute coronary syndrome or percutaneous coronary intervention, use of aspirin immediately and for up to 30 days results in an equal tradeoff between an increase in severe bleeding and a reduction in severe ischemic events, but after 30 days, aspirin continues to increase bleeding without significantly reducing ischemic events.

Considerations for Aspirin Use

• The decision to give aspirin to a patient on Xarelto for atrial fibrillation with chest pain should be based on the individual patient's risk profile and the clinical context, taking into account the potential benefits and risks of aspirin therapy, as discussed in 7.
• The patient's history of atrial fibrillation and current use of Xarelto should be considered, as well as the presence of any other comorbidities or risk factors that may influence the decision to use aspirin.