Should aspirin be bridged until rivaroxaban (Xarelto) can be resumed in a patient with a history of atrial fibrillation (AF) and a stent, currently on prophylactic clexane (enoxaparin) post-operatively?

From the Guidelines

Bridging with aspirin is not recommended for a patient with atrial fibrillation and a stent who is currently on prophylactic enoxaparin post-operatively until rivaroxaban can be resumed. Instead, the patient should continue on prophylactic enoxaparin until rivaroxaban can be safely restarted, typically when adequate hemostasis is achieved and the risk of surgical bleeding has decreased. For most patients, rivaroxaban can be resumed 24-72 hours after surgery, depending on the bleeding risk of the procedure. When restarting rivaroxaban, the first dose should be given at least 12 hours after the last dose of enoxaparin. Adding aspirin as a bridge could significantly increase bleeding risk without providing additional thrombotic protection in this scenario. The prophylactic enoxaparin provides some protection against both venous thromboembolism and, to a lesser extent, arterial thromboembolism during the perioperative period. However, if the patient's stent was placed recently (within the past 6 months) or if they have very high thrombotic risk factors, consultation with both cardiology and the surgical team is warranted to create an individualized plan that balances bleeding and thrombotic risks, as suggested by the 2021 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease 1.

Some key points to consider in this decision include:

• The risk of stent thrombosis, which is relatively low in patients with a stent placed more than 6 months prior to surgery, as seen in the AUGUSTUS trial 1
• The increased risk of bleeding associated with bridging anticoagulation, as discussed in the 2018 update on antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention 1
• The importance of individualizing the plan based on the patient's specific risk factors and clinical scenario, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1

Overall, the decision to bridge with aspirin should be made on a case-by-case basis, taking into account the patient's individual risk factors and the potential benefits and risks of bridging anticoagulation. However, in general, bridging with aspirin is not necessary and may increase the risk of bleeding without providing additional thrombotic protection.

From the FDA Drug Label

If anticoagulation must be discontinued to reduce the risk of bleeding with surgical or other procedures, XARELTO should be stopped at least 24 hours before the procedure to reduce the risk of bleeding [see Warnings and Precautions (5. 2)] . XARELTO should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established, noting that the time to onset of therapeutic effect is short [see Warnings and Precautions (5.1)] .

The patient is currently on prophylactic clexane (enoxaparin) post-operatively, and rivaroxaban (Xarelto) can be resumed in 3 days. Bridging with aspirin is not explicitly mentioned in the drug label. However, considering the patient has a history of atrial fibrillation (AF) and a stent, caution should be exercised to prevent thromboembolic events. Since the label does not provide direct guidance on bridging with aspirin, no conclusion can be drawn. 2

From the Research

Antithrombotic Therapy in Patients with Atrial Fibrillation and Stents

The management of antithrombotic therapy in patients with atrial fibrillation (AF) who have undergone coronary artery stenting is complex, requiring consideration of both thrombotic and bleeding risks.

• The use of dual therapy, consisting of a single antiplatelet agent (such as clopidogrel) in combination with an oral anticoagulant (like rivaroxaban), is supported by current literature as effective and associated with less bleeding risk than triple therapy (dual antiplatelet therapy plus an oral anticoagulant) in patients with AF undergoing percutaneous coronary intervention (PCI) with stent placement 3.
• Guidelines recommend the use of an oral anticoagulant plus clopidogrel and aspirin for a short period, with aspirin generally discontinued at discharge, except in patients with a high risk of thrombosis, where it may be continued for up to 1 month 3.
• A case report illustrates the safety and efficacy of triple therapeutic targets with rivaroxaban after acute myocardial infarction complicated by left ventricular thrombi in a patient with nonvalvular atrial fibrillation, initially treated with short-term triple therapy including aspirin, clopidogrel, and rivaroxaban, then switched to dual therapy with clopidogrel and rivaroxaban after aspirin was dropped one month post-discharge 4.
• Studies have shown that rivaroxaban, in combination with a P2Y12 inhibitor or dual antiplatelet therapy, reduces the risk of all-cause mortality or recurrent hospitalization for adverse events compared to standard treatment with a vitamin K antagonist plus dual antiplatelet therapy in patients with atrial fibrillation undergoing intracoronary stenting 5.

Bridging with Aspirin

Given the patient's history of atrial fibrillation and stent placement, and considering they are currently on prophylactic clexane (enoxaparin) post-operatively with plans to restart rivaroxaban in 3 days, the decision to bridge with aspirin until rivaroxaban can be resumed should be based on the individual's thrombotic and bleeding risk profile.

• There is evidence suggesting that aspirin may be used in the periprocedural period but should be discontinued thereafter to reduce the risk of bleeding 3.
• However, the specific scenario of bridging with aspirin for a patient with a stent and AF, temporarily off rivaroxaban, is not directly addressed in the provided studies, which focus more on long-term antithrombotic strategies rather than short-term bridging therapy.

Considerations

In making a decision, considerations should include the patient's risk of thrombosis, the risk of bleeding, and the timing of rivaroxaban restart. Given the patient is already on prophylactic clexane, the addition of aspirin would need to be carefully considered to avoid increasing the bleeding risk unnecessarily. The patient's individual risk factors and the clinical context should guide the decision-making process, potentially leaning towards a conservative approach given the lack of direct evidence supporting the need for aspirin bridging in this specific scenario.