Can baby aspirin (acetylsalicylic acid) be discontinued in a patient taking Xarelto (rivaroxaban) with stable coronary artery disease (CAD) and no cardiac intervention?

Can Baby Aspirin Be Discontinued in a Patient Taking Xarelto with Stable CAD and No Cardiac Intervention?

Yes, aspirin can be discontinued in patients with stable CAD taking rivaroxaban (Xarelto) alone, as rivaroxaban monotherapy without aspirin is not recommended for stable CAD—the evidence-based regimen is rivaroxaban 2.5 mg twice daily PLUS aspirin 75-100 mg daily, not rivaroxaban alone. If the patient is already on therapeutic-dose rivaroxaban for another indication (such as atrial fibrillation), then aspirin should be discontinued after 12 months from any prior coronary intervention 1.

Understanding the Evidence-Based Regimens

The critical distinction here depends on why the patient is taking Xarelto:

If Rivaroxaban is Being Used for Vascular Protection (2.5 mg twice daily):

• Do NOT discontinue aspirin—the COMPASS trial demonstrated that rivaroxaban 2.5 mg twice daily PLUS aspirin 100 mg daily (dual pathway inhibition) reduced major adverse cardiovascular events by 26% compared to aspirin alone in stable CAD patients (HR 0.74, p<0.0001) 2.

• Rivaroxaban 2.5 mg twice daily alone (without aspirin) showed no significant benefit over aspirin monotherapy for the primary outcome in stable CAD (HR 0.89, p=0.094) 2.

• The combination reduced all-cause mortality by 23% compared to aspirin alone (HR 0.77, p=0.0012), despite increasing major bleeding (HR 1.66) 2, 3.

• This dual pathway inhibition regimen is now guideline-recommended for high-risk stable CAD patients 4.

If Rivaroxaban is Being Used for Anticoagulation (Standard Doses for AF/VTE):

• Aspirin SHOULD be discontinued after the appropriate post-intervention period has elapsed 1.

• For patients with stable CAD who have NOT had recent percutaneous coronary intervention, antiplatelet medications should be stopped entirely when therapeutic anticoagulation is present 1.

• For patients within 12 months of drug-eluting stent placement, clopidogrel (not aspirin) is the preferred antiplatelet agent to combine with anticoagulation for the first 6 months, then either aspirin or clopidogrel can be used from 6-12 months 1.

• After 12 months from the last percutaneous coronary intervention, antiplatelet therapy should be discontinued in patients on therapeutic anticoagulation 1.

Critical Decision Algorithm

Step 1: Determine the indication and dose of rivaroxaban

• If rivaroxaban 2.5 mg twice daily for vascular protection → Continue aspirin 75-100 mg daily 2
• If rivaroxaban 15-20 mg daily for atrial fibrillation/VTE → Proceed to Step 2

Step 2: Determine timing of last coronary intervention

• If no prior PCI/stent → Discontinue aspirin 1
• If <6 months from drug-eluting stent → Switch to clopidogrel (not aspirin) plus anticoagulation 1
• If 6-12 months from drug-eluting stent → Either aspirin or clopidogrel plus anticoagulation 1
• If >12 months from any coronary intervention → Discontinue all antiplatelet therapy 1

Step 3: Assess bleeding vs thrombotic risk

• Triple therapy (aspirin + P2Y12 inhibitor + anticoagulant) should not exceed 30 days and only in highest-risk patients 1.
• Dual therapy (single antiplatelet + anticoagulant) causes more bleeding than anticoagulation alone with no difference in thrombotic events after the appropriate post-PCI period 1.

Common Pitfalls to Avoid

• Do not confuse vascular-dose rivaroxaban (2.5 mg BID) with therapeutic anticoagulation doses—these are entirely different treatment strategies with different evidence bases 2, 3.

• Do not continue aspirin indefinitely in patients on therapeutic anticoagulation for stable CAD without recent intervention—this increases bleeding risk without proven benefit after 12 months 1.

• Do not discontinue aspirin abruptly in patients with recent coronary events or stents—aspirin withdrawal is associated with a three-fold higher risk of major adverse cardiac events (OR 3.14), and up to 89-fold higher risk in patients with intracoronary stents 5.

• Do not use aspirin doses >100 mg—higher doses increase bleeding without improving cardiovascular outcomes 6.

Bleeding Risk Mitigation

• If aspirin must be continued with anticoagulation, add a proton pump inhibitor for gastroprotection, as this is strongly recommended for patients at increased GI bleeding risk 6.

• The most common site of major bleeding with rivaroxaban plus aspirin is gastrointestinal (2% vs 1% with aspirin alone), but there was no significant increase in intracranial bleeding or fatal bleeding 2.

• For patients with prior GI bleeding requiring aspirin, restart aspirin 75-100 mg daily with mandatory PPI therapy once hemodynamic stability is achieved, as mortality benefits substantially outweigh bleeding risks in established CAD 6.