From the Guidelines
For a patient with new NSTEMI and atrial fibrillation, rivaroxaban 15 mg daily is recommended as the preferred DOAC, used in combination with dual antiplatelet therapy (DAPT) consisting of aspirin 81 mg daily and clopidogrel 75 mg daily. This approach is based on the most recent guidelines, specifically the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. The recommended doses for the DOACs in this setting are as follows:
- Apixaban 5 mg b.i.d.
- Dabigatran 110 mg or 150 mg b.i.d.
- Edoxaban 60 mg/d
- Rivaroxaban 15 mg or 20 mg/d Rivaroxaban monotherapy was superior for the primary safety endpoint of major bleeding (HR 0.59,95% CI 0.39-0.89) 1. Key considerations include:
- Dose adjustment for renal impairment
- Alternative options, such as apixaban, if rivaroxaban is contraindicated
- Balancing stroke prevention for atrial fibrillation with reducing recurrent cardiac events from NSTEMI while minimizing bleeding risk. The lower rivaroxaban dose (15 mg vs standard 20 mg for AFib alone) is specifically used in this setting to reduce bleeding complications while maintaining efficacy in this high-risk population requiring multiple antithrombotic agents. It is essential to weigh the benefits and risks of antithrombotic therapy, considering the patient's individual risk factors and preferences, as outlined in the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.
From the Research
Direct Oral Anticoagulant (DOAC) Selection for Patients with NSTEMI and Afib
- The choice of DOAC for patients with new Non-ST-Elevation Myocardial Infarction (NSTEMI) and Atrial Fibrillation (Afib) should be based on individual patient risk profiles 2.
- Available data suggest the use of full-dose direct oral anticoagulants (DOACs) such as dabigatran 150 mg twice daily or apixaban 5 mg twice daily, or rivaroxaban 15 mg once daily in patients with Afib and acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) 2.
- For patients with NSTEMI, anticoagulation may be an important part of the longer-term antithrombotic strategy, especially in those with existing indications for anticoagulation, such as Afib 3.
Comparison of Rivaroxaban and Apixaban
- Studies have compared the effectiveness and safety of rivaroxaban and apixaban in patients with Afib, with some suggesting that apixaban may be associated with a lower risk of major ischemic or hemorrhagic events 4, 5.
- A real-world data study found that patients using rivaroxaban 15 mg had higher ischemic stroke and mortality rates compared to those using rivaroxaban 20 mg, while nonmajor bleeding rates were lower in the 15 mg group 6.
- Another study found that apixaban was associated with a lower rate of ischemic stroke or systemic embolism and bleeding compared to rivaroxaban in routine care 5.
Recommended DOAC Regimen
- Based on the available evidence, apixaban 5 mg twice daily may be a suitable option for patients with NSTEMI and Afib, considering its effectiveness and safety profile 2, 4, 5.
- However, the choice of DOAC should be individualized, taking into account the patient's risk profile and other factors, such as renal function and concomitant medications 2, 3.