Does a patient with coronary artery disease on a heparin (unfractionated heparin) drip, taking aspirin and Effient (prasugrel), still need Xarelto (rivaroxaban)?

Discontinue Xarelto While on Heparin Drip

No, a patient on a heparin drip does not need Xarelto (rivaroxaban) concurrently—parenteral anticoagulation should be discontinued immediately after the invasive procedure, and Xarelto should only be initiated after stopping heparin when transitioning to long-term antithrombotic therapy. 1

Acute Phase Management: Heparin Takes Priority

During the acute coronary syndrome phase and peri-procedural period:

• Unfractionated heparin (UFH) is the recommended anticoagulant during active ACS management and PCI, with dosing of 70-100 U/kg IV bolus when no GP IIb/IIIa inhibitor is planned 1
• Discontinuation of parenteral anticoagulation (heparin drip) should occur immediately after the invasive procedure 1
• Concurrent use of heparin and Xarelto is not indicated and significantly increases bleeding risk without additional benefit 2

The FDA label explicitly warns that combining Xarelto with heparin increases bleeding risk, as both are anticoagulants that affect different parts of the coagulation cascade 2.

Dual Antiplatelet Therapy is the Standard Post-PCI

For this patient already on aspirin and Effient (prasugrel):

• DAPT with aspirin plus prasugrel is the recommended standard treatment for 12 months post-ACS 1
• Prasugrel dosing: 60 mg loading dose, then 10 mg daily (5 mg daily if age ≥75 years or body weight <60 kg) 1
• Aspirin maintenance dose: 75-100 mg daily 1

This DAPT regimen provides robust platelet inhibition without requiring additional anticoagulation during the initial 12-month period 1.

When Xarelto May Be Considered: Extended Therapy Beyond 12 Months

Xarelto 2.5 mg twice daily plus aspirin may be considered only after the initial treatment phase:

• In ACS patients with high ischemic risk and low bleeding risk, rivaroxaban 2.5 mg twice daily plus aspirin may be considered after discontinuation of parenteral anticoagulation 1
• This is a Class IIb recommendation (may be considered), not routine practice 1
• Rivaroxaban 2.5 mg twice daily plus aspirin is specifically indicated for long-term secondary prevention in stable CAD patients, not during acute management 1, 2

The COMPASS trial demonstrated that rivaroxaban 2.5 mg twice daily plus aspirin reduced major cardiovascular events by 24% compared to aspirin alone in stable CAD patients, but this was studied in chronic stable disease, not acute ACS 3, 4.

Critical Timing and Sequencing

The appropriate sequence is:

1. Acute phase (during hospitalization): Heparin drip + aspirin + prasugrel 1, 5
2. Immediately post-procedure: Discontinue heparin 1
3. First 12 months: DAPT with aspirin + prasugrel 1
4. Beyond 12 months (if high ischemic risk): Consider rivaroxaban 2.5 mg twice daily + aspirin (discontinuing prasugrel) 1

Common Pitfalls to Avoid

• Never overlap heparin and Xarelto—this dramatically increases bleeding risk without proven benefit 2
• Triple therapy with aspirin, prasugrel, and rivaroxaban is not recommended in the absence of atrial fibrillation requiring full anticoagulation 1
• Rivaroxaban 2.5 mg twice daily is a specific low-dose regimen for vascular protection, distinct from the full anticoagulation doses (15-20 mg daily) used for atrial fibrillation or VTE 2
• Patients with prior stroke/TIA should not receive rivaroxaban plus DAPT due to excessive bleeding risk 1

Bleeding Risk Assessment

The combination of multiple antithrombotic agents substantially increases bleeding:

• Major bleeding occurs in approximately 3% of patients on rivaroxaban 2.5 mg twice daily plus aspirin versus 2% on aspirin alone 3
• Adding a third agent (prasugrel) would further escalate this risk 1
• The most common site of major bleeding is gastrointestinal 3