Evaluating Apixaban Against VKAs with Aspirin or Placebo in AF

In a post hoc analysis of the AUGUSTUS trial, researchers evaluated apixaban or vitamin K antagonists (VKA) and aspirin or placebo in patients with atrial fibrillation (AF) and recent acute coronary syndrome or percutaneous coronary intervention. They found that apixaban appeared superior to VKAs regardless of prior stroke, transient ischemic attack (TIA), or thromboembolism (TE) history. The analysis was published in JAMA Cardiology.

The study included 4,581 patients, of which 633 (13.8%) had prior stroke/TIA/TE. Compared to patients without, patients with prior stroke/TIA/TE had higher CHA2DS2-VASC and HAS-BLED scores, and more frequently had prior bleeding, heart failure, diabetes, and oral anticoagulant use.

Apixaban Versus VKA With Aspirin or Placebo

In the study, apixaban was associated with lower rates of major or clinically relevant non-major bleeding and death or hospitalization compared with VKA in both patients with prior stroke/TIA/TE (hazard ratio [HR], 0.69; 95% CI, 0.46-1.03) and those without (HR, 0.68; 95% CI, 0.57-0.82).

Notably, the authors found aspirin increased the incidence of bleeding events in patients without prior stroke/TIA/TE—though the difference with aspirin was less prominent in patients with history (P=.01). Conversely, aspirin was associated with numerically lower rates of death or ischemic events than placebo in both patients with (HR, 0.71; 95% CI, 0.42-1.20) and without (HR, 0.93; 95% CI, 0.72-1.21) prior stroke, TIA, or TE.

In short, the authors supported the benefits of apixaban compared with VKA in patients with AF, consistent with the conclusions in the AUGUSTUS trial.

Though the authors observed some benefit with aspirin in patients with prior stroke, they felt their results “support the use of apixaban and a P2Y12 inhibitor without aspirin for the majority of patients with AF and ACS and/or PCI, regardless of prior stroke/TIA/TE status.

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