New Study Reveals Best Antithrombotic Regimen for Atrial Fibrillation Post-ACS/PCI: Apixaban and P2Y12 Inhibitor Shine

The research, published in the Journal of the American College of Cardiology, highlights that a regimen including a P2Y12 inhibitor and apixaban, without aspirin, significantly reduces the incidence of adverse outcomes compared to traditional treatments involving vitamin K antagonists (VKAs), aspirin, or both.

The ideal antithrombotic regimen for patients with atrial fibrillation following ACS or PCI remains unclear. Renato D. Lopes, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA, and colleagues aimed to compare four different antithrombotic regimens to determine which combination offers the best outcomes for reducing death, bleeding, and cardiovascular hospitalization. They investigated which antithrombotic regimen best balances safety and efficacy.

The AUGUSTUS trial, a multicenter randomized study with a 2 × 2 factorial design, compared apixaban to vitamin K antagonist (VKA) therapy and aspirin to placebo in patients with AF who had recently undergone acute coronary syndrome or percutaneous coronary intervention and were receiving a P2Y12 inhibitor. The four-way analysis assessed safety and efficacy across the four randomized groups.

The primary outcome measured was a composite of all-cause mortality, major or clinically relevant non-major bleeding, and hospitalization for cardiovascular reasons over a 6-month follow-up period. Secondary outcomes included the individual components of this primary composite endpoint.

The study led to the following findings:

• A total of 4,614 patients were enrolled. All patients were treated with a P2Y12 inhibitor.
• The primary endpoint occurred in 21.9% of patients randomized to apixaban plus placebo, 27.3% randomized to apixaban plus aspirin, 28.0% randomized to VKA plus placebo, and 33.3% randomized to VKA plus aspirin.
• Rates of major or clinically relevant nonmajor bleeding and hospitalization for cardiovascular causes were lower with apixaban and placebo compared with the other three antithrombotic strategies.
• There was no difference between the four randomized groups for all-cause death.

The findings showed that in patients with atrial fibrillation who had recently experienced acute coronary syndrome or undergone PCI, an antithrombotic regimen combining a P2Y12 inhibitor with apixaban, and excluding aspirin, was associated with a lower rate of the composite outcome of death, bleeding, or cardiovascular hospitalization compared to regimens that included vitamin K antagonists, aspirin, or both.

"The findings support the preference for a regimen combining a direct oral anticoagulant with a P2Y12 inhibitor, as it effectively prevents ischemic events while minimizing bleeding risks in this high-risk patient population," the researchers concluded.

Reference:

Berwanger O, Wojdyla DM, Fanaroff AC, et al. Antithrombotic strategies in atrial fibrillation after ACS and/or PCI. J Am Coll Cardiol. 2024;84:875-885.