Rivaroxaban alone better than combination therapy for stable CAD patients with AF, JAMA study.

Appropriate regimens of antithrombotic therapy for patients with atrial fibrillation (AF) and coronary artery disease (CAD) have not yet been established. Researchers agree that instead of time to first clinical event, trails should elaborate on total clinical events to better assess the safety and efficacy of any drug regimen. In this regard, a secondary analysis of AFIRE trial has recently been published in JAMA Cardiology. This analysis shows that Rivaroxaban monotherapy is associated with lower risks of total thrombotic and/or bleeding events in patients with atrial fibrillation and stable coronary artery disease (compared to rivaroxaban with antiplatelets).

Patients with AF and stable CAD who had undergone percutaneous coronary intervention or coronary artery bypass grafting 1 or more years earlier or who had angiographically confirmed CAD not requiring revascularization were enrolled in this trial.

Patients were randomly assigned in equal numbers to either receive monotherapy with rivaroxaban (10 mg once daily for patients with a creatinine clearance of 15 to 49 mL/min or 15 mg once daily for patients with a creatinine clearance ≥50 mL/min) or combination therapy with rivaroxaban and an antiplatelet agent. The total incidence of thrombotic, bleeding, and fatal events was compared between the groups.

The analysis yielded following important findings:

1. The total event rates for the rivaroxaban monotherapy group and the combination-therapy group were 12.2% and 19.2%, respectively, during a median follow-up of 24.1 months.

2. The mortality rate was 3.7% in the monotherapy group and 6.6% in the combination-therapy group.

3. Rivaroxaban monotherapy was associated with a lower risk of total events compared with combination therapy (hazard ratio= 0.62).

4. Monotherapy was an independent factor associated with a lower risk of subsequent events compared with combination therapy.

5. Bleeding events occurred more frequently and the mortality risk after a bleeding event was higher than that after a thrombotic event.

This study extends the main findings of the AFIRE study, showing a reduction in not only the first events but in the total events. These results reinforce the treatment benefit of rivaroxaban alone with respect to thrombosis and bleeding reduction.

As societies continue to age around the world, bleeding may be a prominent issue on which to focus. Thus, clinicians will have to consider tapering antithrombotic agents in patients with AF after PCI to minimize their bleeding events.

Source: JAMA Cardiology: doi:10.1001/jamacardio.2022.1561