Management of Anticoagulation in ACS Patients on Rivaroxaban Requiring Primary PCI
Patients with acute coronary syndrome who are on rivaroxaban for atrial fibrillation should be switched to parenteral anticoagulation with unfractionated heparin (UFH) or bivalirudin during primary PCI to reduce ischemic events and procedural complications. 1
Rationale for Switching Anticoagulation
- The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for ACS management strongly recommends parenteral anticoagulation for all patients with ACS, regardless of initial treatment strategy 1
- Parenteral anticoagulation is specifically indicated to:
- Treat the underlying pathophysiologic process (coronary atherothrombosis)
- Reduce the risk of recurrent major adverse cardiac events (MACE)
- Support PCI or other reperfusion therapy
Recommended Parenteral Anticoagulation Options
First-Line Option: Unfractionated Heparin (UFH)
- UFH is the standard of care for ACS patients undergoing PCI (Class I, Level C-EO) 1
- Dosing for patients previously on rivaroxaban:
Alternative Option: Bivalirudin
- Bivalirudin is a useful alternative to UFH in patients with STEMI undergoing PCI (Class I, Level B-R) 1
- May be reasonable as an alternative to UFH in NSTE-ACS to reduce bleeding (Class IIb, Level B-R) 1
- Dosing: 0.75 mg/kg bolus, followed by 1.75 mg/kg/h IV infusion during the PCI procedure 1
- Post-PCI infusion for primary PCI: 1.75 mg/kg/h for 2-4 hours post-PCI 1
Important Considerations
Timing of Anticoagulation Switch
- According to the FDA label for rivaroxaban, when switching from rivaroxaban to another anticoagulant:
- Discontinue rivaroxaban
- Give the first dose of the parenteral anticoagulant at the time the next rivaroxaban dose would have been taken 2
Procedural Considerations
- Discontinuation of parenteral anticoagulation should be considered immediately after the invasive procedure (Class IIa, Level C) 1
- For patients who will need to resume oral anticoagulation post-PCI:
- A careful assessment of bleeding and thrombotic risks is necessary
- Consider dual antithrombotic therapy (rivaroxaban plus a P2Y12 inhibitor) after PCI 3
Bleeding Risk Management
- Radial access is preferred over femoral access to reduce bleeding risk 4
- Consider bivalirudin in patients at high risk for bleeding, particularly with femoral access 5
Special Considerations
Potential Benefits of Combination Approach
- Some evidence suggests that adding a bolus dose of UFH in patients treated with bivalirudin during primary PCI may be associated with lower rates of target lesion thrombosis 6
- This approach may be considered in high thrombotic risk scenarios
Post-PCI Anticoagulation
- After PCI, patients with AF will need to resume oral anticoagulation
- Real-world data shows that rivaroxaban in AF patients who underwent PCI has comparable ischemic and bleeding event rates to those observed in clinical trials 3
Common Pitfalls to Avoid
Do not use fondaparinux to support PCI - Fondaparinux should not be used to support PCI because of the risk of catheter thrombosis (Class III: Harm) 1
Avoid crossover between UFH and LMWH - Crossover of UFH and low-molecular-weight heparin is not recommended (Class III, Level B) 1
Do not continue rivaroxaban during the procedure - There is insufficient evidence supporting the safety and efficacy of direct oral anticoagulants during primary PCI for ACS
Do not delay anticoagulation transition - Ensure timely transition from rivaroxaban to parenteral anticoagulation to maintain adequate anticoagulation during the high-risk period of PCI
By following these evidence-based recommendations, clinicians can optimize anticoagulation management in patients with ACS on rivaroxaban for AF who require primary PCI, minimizing both thrombotic and bleeding risks.