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Optimal Treatment for Complex Afib Cases Excludes Aspirin

Atrial fibrillation patients at risk for acute coronary syndrome, stroke and blood clots have better outcomes with an antithrombotic regimen of apixaban without aspirin, researchers report.

NEW ORLEANS―Atrial fibrillation patients at risk for acute coronary syndrome, stroke and blood clots have a lower risk of bleeding and hospitalization with an antithrombotic regimen that includes apixaban without aspirin, according to researchers who presented findings this week at the American College of Cardiology’s annual meeting held in New Orleans.

Complex cases of both atrial fibrillation (Afib) and acute coronary syndrome and/or percutaneous coronary intervention require combined anti-coagulant treatment to reduce stroke risk and antiplatelet therapy to prevent clotting and recurrent coronary ischemic events, but this combination increases the risk of bleeding.

In this study of 4,600 patients, researchers led by Renato Lopes, M.D., Ph.D., of Duke University in North Carolina, set out to determine the optimal antithrombotic treatment for complex cases of Afib. They compared apixaban with vitamin K antagonists and aspirin with placebo in patients with Afib who develop acute coronary syndrome and/or undergo percutaneous coronary intervention while taking a platelet inhibitor.
Patients who received a platelet inhibitor were given either 2.5 mg or 5 mg apixaban tablets twice per day; or, the vitamin K antagonist warfarin once daily and aspirin (81 mg) or an aspirin placebo.

After six months, major or clinically relevant nonmajor bleeding was lower in patients who received apixaban (10.5%) compared to those who received warfarin (14.7%), with a 31% reduction in risk of bleeding associated with apixaban. Major bleeding was also significantly lower in patients receiving the placebo (9%) as compared to aspirin (16.1%), with a 47% reduction in risk of bleeding associated with no aspirin.

The apixaban group had a lower incidence of death or hospitalization. There was an overall similar incidence of ischemic events in all groups. The lowest rates of bleeding―with no increase in deaths or hospitalizations―were seen in patients who received the two-drug regimen and no aspirin.


Renato Lopes, M.D., MHS, Ph.D., Duke University Health System, North Carolina. “An Open-label, 2 x 2 Factorial, Randomized Trial to Evaluate the Safety of Apixaban versus Vitamin K Antagonist and Aspirin versus Placebo in Patients with Atrial Fibrillation and Acute Coronary Syndrome and/or Percutaneous Coronary Intervention: Primary Results of the AUGUSTUS Trial,” AAC.19. Abstract number: 19-LB-19653-ACC. Sunday, March 17, 12:15–1:15 p.m.


The authors disclosed a number of conflicts of interest.