Should a patient with new onset atrial fibrillation starting Xarelto (rivaroxaban) discontinue aspirin (acetylsalicylic acid) 81mg?

From the Guidelines

In patients with new onset atrial fibrillation starting Xarelto, aspirin 81mg should be discontinued unless there is a specific indication for dual therapy, such as recent acute coronary syndrome or coronary stenting, as evidenced by the 2021 American College of Cardiology expert consensus decision pathway 1. When considering the management of anticoagulant and antiplatelet therapy in patients with atrial fibrillation, it is crucial to weigh the risks of thrombosis against the risks of bleeding. The use of Xarelto (rivaroxaban) for stroke prevention in atrial fibrillation is well-established, but the addition of aspirin increases the risk of bleeding without providing significant additional benefit in most cases.

• Key considerations include:
  • The patient's history of TIA 8 years ago does not necessarily mandate continued aspirin use, especially when initiating anticoagulation with Xarelto for atrial fibrillation.
  • The decision to continue or discontinue aspirin should be based on an individualized assessment of the patient's thrombotic and bleeding risks.
  • Patients at high bleeding risk and low ischemic risk may benefit from shorter durations of antiplatelet therapy or its discontinuation, as suggested by the 2021 ACC expert consensus decision pathway 1.
• Monitoring for signs of bleeding is essential when adjusting antithrombotic regimens, and patients should be educated on the signs of bleeding, such as bruising, nosebleeds, blood in urine or stool, or unusual fatigue. The patient's healthcare provider should discuss the risks and benefits of continuing or discontinuing aspirin in the context of starting Xarelto for atrial fibrillation, taking into account the patient's complete medical history and current guidelines, such as those outlined in the 2021 American College of Cardiology expert consensus decision pathway 1.

From the Research

Patient Considerations

• The patient has new onset atrial fibrillation and is starting Xarelto (rivaroxaban), while also taking aspirin 81mg for a transient ischemic attack (TIA) that occurred 8 years ago.
• The decision to continue aspirin along with Xarelto depends on the patient's individual risk factors and medical history.

Relevant Studies

• A study published in 2021 2 found that in patients with atrial fibrillation and stable coronary artery disease, there were no significant differences in primary efficacy and safety end points between those taking rivaroxaban with a P2Y12 inhibitor and those taking rivaroxaban with aspirin.
• Another study from 2017 3 suggested that the combined use of aspirin and oral anticoagulant therapy in patients with atrial fibrillation and stable coronary artery disease may increase the risk of major bleeding with little to no benefit in preventing ischemic events.
• A 2020 review 4 noted that the combined use of anticoagulation and antiplatelet agents can increase the risk of major bleeding events, and that shorter courses with fewer antithrombotic agents may be effective in minimizing bleeding risk while preserving low thrombotic event rates.
• The AFIRE trial 5, published in 2019, found that rivaroxaban monotherapy was noninferior to combination therapy with rivaroxaban and an antiplatelet agent for efficacy and superior for safety in patients with atrial fibrillation and stable coronary artery disease.
• A subanalysis of the AFIRE trial 6 published in 2021 found that the advantages of rivaroxaban monotherapy compared to combination therapy were similar across patients with atrial fibrillation and stable coronary artery disease, irrespective of their risk for stroke and bleeding.

Aspirin Considerations

• The patient's history of TIA 8 years ago may not be a strong indication for continued aspirin use, especially if the patient is now taking Xarelto for atrial fibrillation.
• The studies suggest that the addition of aspirin to anticoagulant therapy may not provide significant benefits in preventing ischemic events, but may increase the risk of major bleeding.
• The decision to continue or discontinue aspirin should be based on a careful assessment of the patient's individual risk factors and medical history, and should be made in consultation with a healthcare provider.