Can patients with a history of cerebral vascular accident (CVA) take Xarelto (rivaroxaban)?

Rivaroxaban Use in Patients with History of CVA

Yes, patients with a history of cerebrovascular accident (CVA) can take Xarelto (rivaroxaban), and it is often recommended for secondary stroke prevention in patients with nonvalvular atrial fibrillation. Rivaroxaban has demonstrated efficacy in preventing recurrent strokes in patients with prior cerebrovascular events, with specific timing considerations after acute events.

Timing of Rivaroxaban Initiation After Stroke

The optimal timing for starting rivaroxaban after an acute ischemic stroke depends on the size of the infarct and bleeding risk:

• Small to medium infarcts: Can typically start rivaroxaban within 3-14 days 1
• Large infarcts: Delay initiation to around 14 days post-stroke 2
• For acute ischemic stroke: Avoid very early anticoagulation (<48 hours) 2

The American Heart Association/American Stroke Association recommends that oral anticoagulation should usually be started within 2 weeks of acute ischemic stroke, though the exact timing within this period must be individualized based on infarct size and bleeding risk 2.

Dosing Considerations

For patients with history of stroke:

• Standard dose: 20 mg once daily with food for patients with normal to moderate renal function (eGFR ≥50 mL/min) 3
• Reduced dose: 15 mg once daily with food for patients with moderate to severe renal impairment (eGFR 15-49 mL/min) 4, 3

Special Considerations

Renal Function

• Rivaroxaban is partially eliminated via the kidneys (approximately 33-35%) 4
• Contraindicated in patients with eGFR <15 mL/min 4, 3
• Regular monitoring of renal function is essential, especially in patients with fluctuating renal function 4

Type of Cerebrovascular Event

1. For patients with prior ischemic stroke due to atrial fibrillation:

   • Rivaroxaban is indicated for secondary prevention 2
   • In the ROCKET AF trial, rivaroxaban was non-inferior to warfarin in patients with prior stroke history 2

2. For cerebral venous thrombosis (CVT):

   • Limited evidence suggests rivaroxaban may be safe and effective 5, 6
   • Small studies have shown high recanalization rates (86% at 6 months, 100% at 12 months) 5

3. For embolic stroke of undetermined source (ESUS):

   • Rivaroxaban was not superior to aspirin and had higher bleeding risk 7
   • Not recommended for this specific indication

Bleeding Risk

• Rivaroxaban carries an increased risk of bleeding compared to antiplatelet therapy alone 7
• In patients with prior stroke, the primary safety endpoint (bleeding) occurred in 3.5% of rivaroxaban users versus 3.9% of warfarin users 2
• For management of major bleeding, consider prothrombin complex concentrate (PCC) at 25-50 U/kg 2

Practical Recommendations

1. After acute ischemic stroke with atrial fibrillation:

   • Delay rivaroxaban initiation based on infarct size:
     • Small infarcts (<4.0 cm³): Start around day 3
     • Medium infarcts (4.0-22.5 cm³): Start around day 3-5
     • Large infarcts (>22.5 cm³): Start around day 6-14 1

2. For patients transitioning from other anticoagulants:

   • Ensure appropriate overlap when switching from warfarin or parenteral anticoagulants 3

3. For patients with both CAD/PAD and history of stroke:

   • Consider low-dose rivaroxaban (2.5 mg twice daily) plus low-dose aspirin for secondary prevention 2
   • This combination reduces major adverse cardiovascular events but increases bleeding risk

Common Pitfalls to Avoid

1. Premature discontinuation: Stopping rivaroxaban increases thrombotic risk; consider bridge therapy if interruption is necessary 3

2. Inadequate dose adjustment for renal impairment can lead to bleeding complications 4

3. Concomitant use with strong CYP3A4 inhibitors or inducers can affect rivaroxaban levels 4

4. Starting too early after large stroke increases risk of hemorrhagic transformation 2

5. Using rivaroxaban in patients with mechanical heart valves is not recommended 3

By following these evidence-based guidelines, rivaroxaban can be safely and effectively used in patients with a history of CVA, particularly for those with nonvalvular atrial fibrillation requiring secondary stroke prevention.