Management of Embolic Myocardial Infarction After Apixaban Therapy
For a patient with embolic myocardial infarction after being on Eliquis (apixaban), switching to Xarelto (rivaroxaban) is recommended as it has shown superior efficacy in reducing mortality and cardiovascular events in post-myocardial infarction patients.
Rationale for Switching from Apixaban to Rivaroxaban
- Rivaroxaban has demonstrated a significant reduction in all-cause mortality compared to placebo after myocardial infarction in patients without an indication for anticoagulation (RR 0.82,95% CI 0.69 to 0.98), suggesting superior efficacy in post-MI settings 1
- Head-to-head comparisons have shown that mortality and ischemic stroke rates in patients treated with rivaroxaban were lower compared with apixaban (HR 0.88; 95% CI 0.78-0.99 and HR 0.92; 95% CI 0.86-0.99, respectively) 2
- Rivaroxaban is associated with a significantly lower risk of myocardial infarction compared to other anticoagulants in a broad spectrum of patients (odds ratio, 0.82; 95% confidence interval, 0.72-0.94) 3
- Case reports have documented successful dissolution of left ventricular thrombi in patients with anterior ST-elevation MI using rivaroxaban in addition to dual antiplatelet therapy 4
Dosing Considerations for Rivaroxaban
- Standard dosing for rivaroxaban is 20 mg once daily with food for patients with normal renal function 5
- For patients with CrCl ≤50 mL/min, the dose should be reduced to 15 mg once daily with food 5
- When switching from apixaban to rivaroxaban, start rivaroxaban 0 to 2 hours prior to the next scheduled dose of apixaban and omit the apixaban dose 5
Monitoring and Follow-up
- Assess renal function before initiation of rivaroxaban and at least annually thereafter 6
- Evaluate hepatic function before starting rivaroxaban 6
- Monitor for signs of bleeding, particularly gastrointestinal bleeding, as rivaroxaban has shown a higher rate of GI bleeding compared with apixaban (HR 1.22; 95% CI 1.01-1.44) 2
- Rivaroxaban has demonstrated a lower rate of intracranial hemorrhage compared with apixaban (HR 0.86; 95% CI 0.74-1.0) 2
Antiplatelet Therapy Considerations
- For patients with recent MI, dual antiplatelet therapy (DAPT) in the form of aspirin plus a P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) is recommended for 12 months after PCI, unless there are contraindications such as excessive bleeding risk 6
- When combining rivaroxaban with antiplatelet therapy, consider using a reduced dose of rivaroxaban (15 mg daily) to minimize bleeding risk 7
- The ATLAS ACS-2-TIMI-51 trial showed that rivaroxaban 2.5 mg twice daily reduced cardiovascular death (2.5% vs. 4.2%, p = 0.006) in STEMI patients when added to standard antiplatelet therapy 7
Cautions and Contraindications
- Rivaroxaban is contraindicated in patients with severe renal impairment (CrCl <15 mL/min) 5
- Do not use rivaroxaban in patients with antiphospholipid antibody syndrome 6
- If a procedure is needed, rivaroxaban should be stopped at least 24 hours before the procedure to reduce bleeding risk 5
- For invasive procedures with high bleeding risk, interrupt rivaroxaban three days before the procedure 6
Alternative Options if Rivaroxaban is Contraindicated
- If rivaroxaban is contraindicated, consider warfarin with a target INR of 2.0-3.0, with attention to individual time in therapeutic range (TTR), ideally ≥70% 6
- For patients with prior gastrointestinal bleeding, apixaban or dabigatran 110 mg bid may be preferable as they are associated with a lower risk of gastrointestinal bleeding compared with warfarin 6
- For patients at high risk of ischemic stroke, dabigatran 150 mg twice daily is recommended as it has superior efficacy compared with warfarin 6
By switching from apixaban to rivaroxaban in this patient with embolic myocardial infarction, you are providing an anticoagulant that has demonstrated better outcomes specifically in post-MI settings while maintaining an acceptable safety profile.