From the Publishers of
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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