When to Stop Aspirin Before Starting Rivaroxaban
In patients with cardiovascular disease requiring rivaroxaban, aspirin should typically be stopped immediately when starting rivaroxaban, with the specific timing dependent on the clinical indication for anticoagulation and the patient's cardiovascular history.
Clinical Decision Algorithm
The timing of aspirin discontinuation depends critically on why the patient needs rivaroxaban and their cardiovascular history:
For Patients Starting Rivaroxaban for VTE (New Blood Clot)
Stop aspirin immediately and start rivaroxaban alone in most scenarios 1:
- Primary prevention of cardiovascular disease: Stop aspirin, start rivaroxaban alone 1
- Stable ischemic heart disease (SIHD) without prior revascularization: Stop aspirin, start rivaroxaban alone 1
- >12 months post-PCI: Stop aspirin, start rivaroxaban alone 1
- >12 months post-ACS: Stop aspirin, start rivaroxaban alone 1
- >1 year post-CABG: Stop aspirin, start rivaroxaban alone 1
For Patients with Recent Coronary Interventions
Continue clopidogrel (not aspirin) with rivaroxaban in these high-risk scenarios 1:
- <6 months post-PCI: Stop aspirin, continue clopidogrel, add rivaroxaban 1
- 6-12 months post-PCI: Continue either aspirin OR clopidogrel (not both) with rivaroxaban until 1 year post-PCI, then stop antiplatelet therapy 1
- <12 months post-ACS: Stop aspirin, continue clopidogrel (switch from prasugrel/ticagrelor if needed), add rivaroxaban 1
- <1 year post-CABG: Continue aspirin (<100 mg/day) with rivaroxaban 1
For Patients with Atrial Fibrillation Post-PCI
Stop aspirin within 1-4 weeks after PCI 1:
- Aspirin can be stopped immediately if the patient is on clopidogrel plus rivaroxaban and bleeding risk is elevated 1
- Default recommendation is to stop aspirin after 1-4 weeks while maintaining clopidogrel plus rivaroxaban 1
- Triple therapy (aspirin + clopidogrel + rivaroxaban) up to 4 weeks is reasonable only for patients with high thrombotic risk and low bleeding risk 1
Critical Dosing Consideration
Use the correct rivaroxaban dose for the indication 1:
- For VTE treatment: 15 mg twice daily for 21 days, then 20 mg once daily (not the 15 mg AF dose) 1
- For chronic CAD/PAD with aspirin: 2.5 mg twice daily plus aspirin 100 mg daily 2, 3
- Dose reduction required for renal impairment 4
Common Pitfalls to Avoid
Do not continue dual antiplatelet therapy (aspirin + P2Y12 inhibitor) beyond 12 months in stable patients requiring anticoagulation—this dramatically increases bleeding risk without reducing ischemic events 1, 5.
Do not use aspirin alone for stroke prevention in patients with atrial fibrillation—this is explicitly contraindicated and increases mortality 5.
Do not delay stopping aspirin in patients >12 months from their cardiovascular event who need anticoagulation for VTE—the bleeding risk of combination therapy outweighs any cardiovascular benefit 1.
Do not use the atrial fibrillation dose of rivaroxaban (15 mg daily) when treating VTE—the VTE treatment dose is 20 mg daily after the initial 21-day loading period 1.
Special Populations
For patients with chronic stable CAD or PAD where rivaroxaban 2.5 mg twice daily is being added to aspirin for cardiovascular protection (not for VTE or AF), this represents a different indication where aspirin is continued alongside low-dose rivaroxaban 6, 7, 2, 3. This combination reduced major adverse cardiovascular events by 24-28% compared to aspirin alone, with a number needed to treat of 42 in heart failure patients 6.