Discontinue Aspirin in This Patient
In a patient with atrial fibrillation and prior stroke taking rivaroxaban, aspirin should be discontinued unless there is a specific acute coronary indication. The combination of anticoagulation with antiplatelet therapy increases bleeding risk without proven benefit for recurrent stroke prevention in this setting.
Rationale for Discontinuing Aspirin
Lack of Efficacy for Stroke Prevention
- Adding antiplatelet treatment to anticoagulation is not recommended in patients with AF to prevent recurrent embolic stroke 1
- Antiplatelet drugs like aspirin are not an alternative to oral anticoagulation and should not be used for stroke prevention in AF, as they can lead to potential harm, especially in elderly patients 1
- The combination of oral anticoagulation with antiplatelet agents without an adequate indication occurs frequently in clinical practice but shows no clear benefit in terms of prevention of stroke or death 1
Increased Bleeding Risk Without Benefit
- Bleeding events are significantly more common when antithrombotic agents are combined 1
- The combination of aspirin with oral anticoagulants should only occur in selected patients with acute vascular disease (e.g., acute coronary syndromes or recent stenting) 1
- In patients with AF at high risk of stroke (which includes those with prior stroke), oral anticoagulation alone is the optimal therapy 1
Rivaroxaban Monotherapy is Appropriate
Adequate Stroke Prevention
- For patients with AF and prior stroke or TIA, rivaroxaban 20 mg daily (or 15 mg daily if CrCl 15-50 mL/min) provides effective stroke prevention as monotherapy 1, 2
- Rivaroxaban demonstrated non-inferiority to warfarin in the ROCKET AF trial, which included 55% of subjects with prior stroke, TIA, or systemic embolism 1
- Among subjects with a history of prior stroke, TIA, or systemic embolism, rivaroxaban showed comparable efficacy to warfarin for secondary prevention 1
Safety Profile
- Rivaroxaban showed lower rates of intracranial hemorrhage (0.5% versus 0.7%, P=0.02) and fatal bleeding (0.2% versus 0.5%, P=0.003) compared to warfarin 1
- The treatment effect for rivaroxaban versus warfarin is broadly consistent across patient groups at high risk for adverse outcomes, including those with prior stroke 3
Specific Exceptions Where Aspirin May Continue
Recent Percutaneous Coronary Intervention
- If the patient underwent PCI with stenting, dual therapy with rivaroxaban 15 mg daily plus a P2Y12 inhibitor (typically clopidogrel, not aspirin) is preferred over triple therapy 1, 4
- This regimen should be used for up to 12 months post-PCI, then transition to oral anticoagulation alone 4
- Triple therapy (rivaroxaban + aspirin + P2Y12 inhibitor) increases bleeding risk and should be minimized in duration 1
Acute Coronary Syndrome
- Aspirin use should continue in the early stages following acute coronary syndrome, in combination with oral anticoagulant drugs and clopidogrel as appropriate 5
- However, this is a time-limited indication, not a chronic therapy 1
Common Pitfalls to Avoid
- Do not continue aspirin "just in case" for cardiovascular protection - the bleeding risk outweighs any theoretical benefit when the patient is already anticoagulated 1
- Do not use aspirin-clopidogrel combination as a substitute for anticoagulation - this provides inadequate stroke protection with similar bleeding risk to warfarin 6
- Ensure proper rivaroxaban dosing - 20 mg daily for normal renal function (CrCl ≥50 mL/min) or 15 mg daily for moderate renal impairment (CrCl 15-50 mL/min) 2
- Consider proton pump inhibitor therapy to reduce gastrointestinal bleeding risk when anticoagulation is used 4