What is the best approach for anticoagulation in a patient with a left atrial appendage thrombus who was previously on Xarelto (Rivaroxaban)?

From the Guidelines

For a patient with a left atrial appendage thrombus who was previously on Rivaroxaban (Xarelto), the best approach is to switch to therapeutic dose warfarin with a target INR of 2.0-3.0, typically for at least 3-4 weeks or until thrombus resolution is confirmed by repeat imaging. This recommendation is based on the presence of a thrombus while on Rivaroxaban, suggesting treatment failure with this direct oral anticoagulant (DOAC) 1. The 2024 ESC guidelines for the management of atrial fibrillation emphasize the importance of anticoagulation in preventing thromboembolism, and in cases where a thrombus is present, a more traditional anticoagulant like warfarin may be preferred due to its extensive clinical experience in treating established thrombi and the ability to monitor anticoagulation intensity through INR testing.

Key considerations in managing such patients include:

• The need for close monitoring with follow-up transesophageal echocardiography after 3-4 weeks of therapy to confirm thrombus resolution before considering any changes to the anticoagulation regimen.
• The importance of assessing the patient's underlying risk factors for thromboembolism and bleeding, using tools like the CHA2DS2-VA score, to guide long-term anticoagulation strategy after thrombus resolution.
• The potential role of non-pharmacological therapies, such as left atrial appendage closure/occlusion devices, in patients with high thrombotic risk and contraindications to anticoagulation, as discussed in the 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants 1.

During the transition to warfarin, overlap with low molecular weight heparin (such as enoxaparin 1 mg/kg twice daily) is advised until the INR reaches the therapeutic range. This approach balances the need to effectively anticoagulate the patient to prevent further thrombus formation with the risk of bleeding associated with anticoagulant therapy.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Anticoagulation Approach for Left Atrial Appendage Thrombus

The management of a patient with a left atrial appendage (LAA) thrombus who was previously on Xarelto (Rivaroxaban) involves careful consideration of anticoagulation strategies.

• The patient's history of Xarelto use and the presence of an LAA thrombus suggest a need for effective anticoagulation to prevent further thromboembolic events 2.
• Studies have shown that intensification of antithrombotic therapy (IAT) can be an effective strategy for managing LAA thrombus, with total thrombus resolution observed in 60.3% and 75.3% of patients after initial and subsequent IAT, respectively 2.
• However, the use of direct oral anticoagulants (DOACs) such as Xarelto may also be considered, as they have been shown to be effective in preventing thromboembolic events in patients with nonvalvular atrial fibrillation 3, 4.
• The CHA2DS2VASc score can be used to assess the risk of thromboembolic events in patients with atrial fibrillation, but it may not be informative about LAA thrombus formation specifically 5.
• Other risk factors, such as the presence of coronary artery disease and systolic dysfunction, may also be associated with an increased risk of LAA thrombus formation 5.

Considerations for Xarelto Use

• The patient's prior use of Xarelto and the presence of an LAA thrombus suggest that the current dose of Xarelto may not be sufficient to prevent thromboembolic events.
• Reducing or discontinuing Xarelto may increase the risk of thromboembolic events, and therefore, an alternative anticoagulation strategy may be necessary 3.
• The use of reduced- or half-dose Xarelto has been shown to be a feasible antithrombotic therapy in patients at high risk of bleeding, but its effectiveness in preventing thromboembolic events in patients with LAA thrombus is not well established 3.

Next Steps

• A comprehensive assessment of the patient's risk factors for thromboembolic events, including the CHA2DS2VASc score and other clinical and biomarker risk factors, is necessary to determine the best approach for anticoagulation.
• Transesophageal echocardiography (TEE) or other imaging modalities may be necessary to confirm the presence of an LAA thrombus and to guide anticoagulation therapy 2, 4.
• Consultation with a cardiologist or other specialist may be necessary to determine the best approach for anticoagulation in this patient, taking into account their individual risk factors and medical history.