From the Guidelines
For a patient with rate-controlled atrial fibrillation on Xarelto (rivaroxaban) who presents with aphasia and progressive stroke, immediate neurological consultation and emergent neuroimaging (CT or MRI) should be obtained before administering any antithrombotic therapy, and aspirin should not be given immediately. The management of such a patient involves a careful assessment of the risks and benefits of antithrombotic therapy, considering the increased risk of bleeding with thrombolytics in the presence of rivaroxaban 1.
Initial Management
- Obtain immediate neurological consultation
- Emergent neuroimaging (CT or MRI) to confirm the nature of the stroke
- Supportive care, including blood pressure control
- Consideration of mechanical thrombectomy if a large vessel occlusion is identified and the patient is a candidate
Antithrombotic Therapy Considerations
- Aspirin should not be initiated immediately due to the potential increased risk of bleeding, especially if the patient has taken Xarelto within the last 24 hours 1.
- Thrombolytic therapy with tPA is generally contraindicated if the patient took Xarelto within the last 24 hours due to increased bleeding risk.
- The stroke team will reassess antithrombotic therapy after the acute phase, which may involve continuing Xarelto or adjusting the regimen based on the presumed etiology of the stroke despite anticoagulation 1.
Long-term Considerations
- This situation represents a "breakthrough stroke" while on anticoagulation and requires careful evaluation of medication adherence, dosing adequacy, and possible alternative stroke mechanisms.
- The selection of antithrombotic therapy should be based on the risk of thromboembolism, and for patients with nonvalvular AF, the CHA2DS2-VASc score is recommended for assessment of stroke risk 1.
Given the complexity of managing a patient with atrial fibrillation on anticoagulation who presents with a stroke, it is crucial to prioritize minimizing the risk of further bleeding while maximizing the prevention of subsequent strokes, guided by the most recent and highest quality evidence available 1.
From the Research
Patient Presentation
The patient presents with rate-controlled atrial fibrillation (Afib) on Xarelto (rivaroxaban) and exhibits symptoms of aphasia and progressive stroke.
Management Considerations
- The patient's current anticoagulation therapy with rivaroxaban may not be sufficient to prevent ischemic events, as evidenced by the occurrence of stroke 2.
- Adding aspirin to the patient's regimen may increase the risk of bleeding, as rivaroxaban is already an anticoagulant 3, 4.
- The use of rivaroxaban in patients with atrial fibrillation has been shown to be effective in preventing stroke and systemic embolism, but it may not be sufficient in patients with a history of ischemic events 5, 6.
Potential Next Steps
- Consider alternative anticoagulation therapies or adjust the current dose of rivaroxaban, taking into account the patient's renal function and other comorbidities 6.
- Monitor the patient closely for signs of bleeding or ischemic events, and adjust the treatment plan accordingly 4, 5.
- Evaluate the patient's overall risk-benefit profile to determine the best course of treatment, considering factors such as stroke risk, bleeding risk, and renal function 2, 3.