How long should a patient with coronary artery disease, who underwent percutaneous coronary intervention (PCI) to the left anterior descending (LAD) artery and is on Xarelto (rivaroxaban), continue taking aspirin?

Duration of Aspirin Therapy in a Patient with PCI to LAD on Xarelto

For a patient who had PCI to LAD and is on both aspirin and rivaroxaban (Xarelto), aspirin should be discontinued after 1-3 months while continuing rivaroxaban alone for long-term anticoagulation.

Understanding the Clinical Scenario

This patient presents with a complex antithrombotic regimen including:

• History of PCI to LAD (coronary stenting)
• Currently on dual therapy with aspirin and rivaroxaban (Xarelto)

The key clinical question involves determining the optimal duration of aspirin therapy in this setting, considering the patient is already on an oral anticoagulant (Xarelto).

Evidence-Based Approach to Aspirin Duration

For Patients on Oral Anticoagulants After PCI

According to the 2020 ACC Expert Consensus Decision Pathway:

• If <6 months since PCI: Stop aspirin, continue P2Y12 inhibitor (clopidogrel), and continue anticoagulation 1
• If 6-12 months since PCI: Continue single antiplatelet therapy (either aspirin or clopidogrel) until 1 year post-PCI, along with anticoagulation 1
• If >12 months post-PCI: Anticoagulation alone can be used long-term 1

The 2016 ACC/AHA guidelines state that aspirin therapy is almost always continued indefinitely in patients with coronary artery disease, but those who develop a high risk of bleeding (e.g., treatment with oral anticoagulant therapy) may require modification of this approach 1.

Balancing Bleeding and Thrombotic Risks

The combination of antiplatelet therapy with anticoagulation significantly increases bleeding risk:

• Triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) carries the highest bleeding risk
• Dual therapy (single antiplatelet + anticoagulant) offers a better safety profile while maintaining efficacy

Recent evidence suggests that discontinuation of aspirin with continued P2Y12 inhibitor monotherapy reduces the risk of bleeding by 40% when stopped 1-3 months after PCI, without an increased risk of major adverse cardiovascular events 2.

Recommended Management Algorithm

1. Determine time since PCI and presence of risk factors:

   • Time since PCI procedure
   • Presence of high thrombotic risk features (complex stenting, ACS presentation)
   • Bleeding risk factors

2. Apply evidence-based duration of aspirin therapy:

   • <1 month post-PCI: Continue aspirin + P2Y12 inhibitor + rivaroxaban (triple therapy)
   • 1-3 months post-PCI: Discontinue aspirin, continue P2Y12 inhibitor + rivaroxaban
   • >3-6 months post-PCI: Consider discontinuing P2Y12 inhibitor, continue rivaroxaban alone

3. Long-term management:

   • After 12 months: Rivaroxaban monotherapy is appropriate for most patients 1

Important Clinical Considerations

• Stent type matters: Drug-eluting stents may require longer DAPT duration than bare metal stents 1, 3
• Bleeding risk assessment: Patients on triple therapy have substantially higher bleeding risk
• Patient education: Explicitly instruct patients not to stop antiplatelet therapy without consulting their cardiologist 3
• Dosing considerations: When combining antiplatelet therapy with rivaroxaban, lower doses of aspirin (75-100mg) should be used to minimize bleeding risk 1

Pitfalls to Avoid

1. Prolonged triple therapy: Extended triple therapy significantly increases bleeding risk without clear ischemic benefit
2. Premature discontinuation: Stopping all antiplatelet therapy too early (<1 month) after PCI increases stent thrombosis risk
3. Failure to reassess: Antithrombotic regimens should be reassessed at regular intervals (1,3,6, and 12 months)
4. Overlooking drug interactions: Monitor for interactions between antiplatelet agents and rivaroxaban

In conclusion, the optimal approach is to limit aspirin duration to 1-3 months after PCI in patients on rivaroxaban, followed by either single antiplatelet therapy plus anticoagulation or anticoagulation alone depending on time since PCI and individual risk factors.