From the Guidelines
For patients with atrial fibrillation after stent placement, the recommended anticoagulation regimen is Xarelto 15 mg once daily plus Plavix 75 mg once daily for 6 months, as this dual therapy regimen balances stroke prevention needed for AF with prevention of stent thrombosis, as suggested by the 2018 Chest guideline and expert panel report 1. The standard approach is to use this combination for a period of 6 months, after which patients usually transition to Xarelto monotherapy. This regimen reduces bleeding risk compared to triple therapy approaches that include aspirin. Key considerations include:
- Dose adjustments are necessary for patients with renal impairment, with a recommended dose of 15 mg daily for those with creatinine clearance 15-49 mL/min.
- It's essential to take Xarelto with food to enhance absorption, maintain consistent timing of doses, and avoid abrupt discontinuation which could increase thrombotic risk.
- Regular monitoring for bleeding complications is crucial, especially during the dual therapy period. The duration of dual therapy may be shortened to 1-3 months for patients at higher bleeding risk or extended beyond 6 months for those with complex stenting or high thrombotic risk, as indicated by the HAS-BLED score 1. Additionally, the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation also support the use of dual therapy with oral anticoagulation and a P2Y12 inhibitor, such as clopidogrel, for patients with atrial fibrillation after stent placement 1. The PIONEER AF-PCI study also demonstrated the safety and efficacy of low-dose rivaroxaban (15 mg once daily) plus a P2Y12 inhibitor (clopidogrel) for 12 months in patients with non-valvular AF who underwent PCI with stenting 1.
From the Research
Anticoagulation Regimen for Patients with Atrial Fibrillation after Stent Placement
The recommended anticoagulation regimen for patients with Atrial Fibrillation (AF) after stent placement, using Xarelto (Rivaroxaban) and Plavix (Clopidogrel), is as follows:
- Dual antithrombotic therapy with a direct-acting oral anticoagulant (DOAC) such as rivaroxaban and a P2Y12 inhibitor like clopidogrel is effective and associated with less bleeding risk than triple therapy 2, 3.
- The use of rivaroxaban 15 mg once daily in patients with AF and acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) is promoted 3.
- Dual therapy with dabigatran and a P2Y12 inhibitor has been shown to be noninferior to triple therapy with warfarin, a P2Y12 inhibitor, and aspirin with respect to the risk of thromboembolic events 4.
Key Considerations
- The choice of antithrombotic therapy should be tailored according to the individual patient's risk profile to reduce the bleeding risk and maintain antithrombotic effect 3.
- Aspirin may be used in the periprocedural period but should be discontinued thereafter to reduce the risk of bleeding 2.
- Decisions regarding specific agents and duration of treatment should be based on thrombotic risk, bleeding risk, and patient preference 2.