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Too Close for Comfort?
For How Long Must I Stop This
Anticoagulant For an Epidural?
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Patel MR, Mahaffey KW, Garg J et al. Rivaroxaban versus Warfarin in
Nonvalvular Atrial Fibrillation. N Engl J Med, 2011; 365: 883-91
Patel MR, Mahaffey KW, Garg J et al. Rivaroxaban versus Warfarin in
Nonvalvular Atrial Fibrillation. N Engl J Med, 2011; 365: 883-91
Rocket AF
The Black Box warning rationale
What happened during the 30 days after study
completion?
What has led to the Black Box Warning?
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What happened at completion of study?
Warfarin patients continued warfarin
Rivaroxaban patients discontinued study drug and then
began warfarin
Not anticoagulated during warfarin titration
Strokes during the 30 days post study
Warfarin group: 6
Rivaroxaban group: 22
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What was the cause of the post study strokes?
Prothrombotic state (Doubt it)
No difference in MI post study
During study there was no difference in stroke in patients
who stopped drug > 3 days
Study drug: 2307 treatment interruptions > 3 days
9 strokes
Warfarin group: 2668 treatment interruptions>3 days
8 strokes
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What was the cause of the post study strokes?
Inadequate anticoagulation?
High risk patients – mean CHADS2 3.5 or higher
Anticoagulation interruption in the rivaroxaban group
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CHADS2 Score
Congestive Heart Failure
Hypertension
Age greater than 75
Diabetic
Stroke
Greater than 3.5 =High Risk of Stroke
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Mrs. W
CHADS2 = 2
Discontinue the rivaroxaban
48 hours prior to epidural
Restart the rivaroxaban
48 hours after epidural
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