How should anticoagulation and antiplatelet therapy be managed in a patient on Xarelto (rivaroxaban) and Brilinta (ticagrelor) post-PCI?

Management of Anticoagulation and Antiplatelet Therapy in Patients on Rivaroxaban and Ticagrelor Post-PCI

For patients on Xarelto (rivaroxaban) and Brilinta (ticagrelor) post-PCI, aspirin should be discontinued while continuing rivaroxaban and ticagrelor as dual therapy to reduce bleeding risk while maintaining adequate protection against thrombotic events.

Recommended Approach Based on Time Since PCI

Immediate Post-PCI Period

• Initial triple therapy (rivaroxaban + ticagrelor + aspirin) should be limited to the shortest duration possible 1
• For most patients, aspirin should be discontinued prior to or upon hospital discharge 1
• Only patients at very high thrombotic risk and low bleeding risk should continue aspirin beyond hospital discharge, and even then only for up to 30 days 1

1-3 Months Post-PCI

• Dual therapy with rivaroxaban and ticagrelor is the recommended approach 1
• Rivaroxaban dosing: 15 mg daily if CrCl >50 mL/min; 10 mg daily if CrCl 30-50 mL/min 1
• Ticagrelor should be maintained at 90 mg twice daily 1

3-12 Months Post-PCI

• For most patients, continue dual therapy with rivaroxaban and ticagrelor 1
• Recent evidence suggests ticagrelor monotherapy (without aspirin) reduces bleeding without increasing ischemic events compared to ticagrelor plus aspirin 2, 3
• This suggests the combination of rivaroxaban and ticagrelor provides adequate antithrombotic protection

Beyond 12 Months Post-PCI

• Discontinue antiplatelet therapy and continue rivaroxaban monotherapy at full stroke prevention dose (20 mg daily if CrCl >50 mL/min; 15 mg daily if CrCl 30-50 mL/min) 1
• For selected patients at high thrombotic risk and low bleeding risk, continuation of a single antiplatelet agent may be reasonable 1

Risk Stratification Considerations

High Thrombotic Risk Features (may warrant longer antiplatelet therapy)

• Recent acute coronary syndrome (<6 months)
• Complex PCI procedure (multiple stents, long stents, bifurcation stenting)
• History of stent thrombosis
• Left main or proximal LAD stenting
• Multiple prior myocardial infarctions

High Bleeding Risk Features (favor shorter antiplatelet therapy)

• Prior major bleeding
• Age ≥75 years
• Low body weight (≤60 kg)
• Chronic kidney disease (CrCl <50 mL/min)
• Concomitant use of medications that increase bleeding risk
• Anemia or thrombocytopenia

Important Clinical Considerations

1. Dosing of Rivaroxaban: The dose that was studied in the PIONEER AF-PCI trial for patients post-PCI with AF was 15 mg daily (reduced to 10 mg daily with CrCl 30-50 mL/min) when combined with a P2Y12 inhibitor 1

2. Choice of P2Y12 Inhibitor: While clopidogrel has been more extensively studied in combination with oral anticoagulants, ticagrelor may be considered in selected patients at high thrombotic risk and low bleeding risk 1

3. Bleeding Prevention Strategies:

   • Use radial access for PCI when possible 1
   • Consider proton pump inhibitor therapy 1
   • Regular monitoring of renal function to ensure appropriate rivaroxaban dosing 4
   • Avoid NSAIDs and other medications that increase bleeding risk

4. Switching Between Anticoagulants: When transitioning from warfarin to rivaroxaban, start rivaroxaban once INR is below 3.0 4

5. Perioperative Management: If surgery is needed, stop rivaroxaban at least 24 hours before the procedure; restart as soon as adequate hemostasis is established 4

Special Scenarios

1. Very High Thrombotic Risk: For patients with recent complex PCI or history of stent thrombosis, triple therapy may be considered for up to 30 days, followed by dual therapy 1

2. Very High Bleeding Risk: Consider switching from ticagrelor to clopidogrel, which has less bleeding risk, while maintaining dual therapy with rivaroxaban 1

3. Recurrent Bleeding on Current Regimen: Consider de-escalation to rivaroxaban plus clopidogrel or rivaroxaban monotherapy (if >6 months post-PCI) 1

The management strategy should be regularly reassessed based on the patient's evolving thrombotic and bleeding risks, with the goal of minimizing bleeding complications while providing adequate protection against thrombotic events.