Apixaban with a P2Y12 inhibitor outperforms other approaches for those with AF and recent acute coronary syndrome or PCI

How to choose antithrombotic therapy for patients with atrial fibrillation and who have an acute coronary syndrome or have undergone percutaneous coronary intervention (PCI)? Oral anticoagulation needed to prevent stroke with AF, but this approach doesn’t stop stent thrombosis. Dual antiplatelet therapy reduces recurrent ischemic events and stent thrombosis but does not tick the box for reduction of cardioembolic stroke with AF. Combining antithrombotic agents and anticoagulation increases bleeding risk. Recently published research appears to point the way. In a study of 4614 patients, major or clinically relevant non-major bleeding was seen amongst in 10.5% of subjects receiving apixaban, compared to 14.7% of those receiving a vitamin K antagonist (hazard ratio, 0.69; 95% confidence interval [CI], 0.58 to 0.81; P<0.001). In 16.1% of subjects receiving aspirin (compared with 9.0% of those receiving placebo) there was important bleeding (hazard ratio, 1.89; 95% CI, 1.59 to 2.24; P<0.001). Those in the apixaban group had a lower incidence of death or hospitalization than those in the vitamin K antagonist group (23.5% vs. 27.4%; hazard ratio, 0.83; 95% CI, 0.74 to 0.93; P=0.002) and a similar incidence of ischemic events. Those receiving in the aspirin had an incidence of death or hospitalization and of ischemic events that was similar to that in the placebo group. In essence, in patients with AF and a recent acute coronary syndrome or PCI treated with a P2Y12 inhibitor, an antithrombotic regimen that included apixaban, without aspirin, had less bleeding and fewer hospitalizations without significant differences in the incidence of ischemic, compared to other regimens that included a vitamin K antagonist, aspirin, or both. Complicated, but worth knowing!