From the Guidelines
Eliquis (apixaban) can be used in patients with atrial fibrillation (AF) and severe aortic stenosis, but careful consideration of the patient's overall clinical status, bleeding risk, and severity of aortic stenosis is necessary. The standard dosing for Eliquis in AF is 5 mg twice daily, or 2.5 mg twice daily for patients meeting at least two of the following criteria: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL, as recommended by the 2019 AHA/ACC/HRS guideline update 1. Key considerations include:
- The patient's bleeding risk, as the use of anticoagulants like apixaban increases the risk of bleeding, particularly in patients with severe aortic stenosis or other comorbidities 1.
- Regular monitoring of renal function, as apixaban is predominantly eliminated hepatically but also has some renal elimination, and dose adjustments may be necessary in patients with severe kidney disease 1.
- The severity of the aortic stenosis, as very severe cases or those with imminent aortic valve replacement may require alternative anticoagulation strategies. The use of Eliquis in this scenario is supported by its efficacy in stroke prevention in AF, as demonstrated in the ARISTOTLE trial, where apixaban was shown to be superior to warfarin in preventing stroke and systemic embolism, with fewer major bleeding events 1. However, consultation with a cardiologist is recommended for personalized guidance in complex cases, especially when considering the use of direct oral anticoagulants like apixaban in patients with valvular heart disease, including severe aortic stenosis.
From the Research
Use of Eliquis (Apixaban) in Atrial Fibrillation (AF) and Severe Aortic Stenosis
- The use of Eliquis (apixaban) in patients with atrial fibrillation (AF) and severe aortic stenosis is a complex issue, with several studies providing insights into its effectiveness and safety 2, 3, 4, 5, 6.
- A study published in the Journal of the American Heart Association in 2021 found that non-vitamin K antagonist oral anticoagulants (NOACs), including apixaban, were associated with a higher risk of thromboembolism but a lower risk of major bleeding compared to warfarin in patients with AF and aortic stenosis 4.
- Another study published in the Journal of the American Heart Association in 2023 found that direct oral anticoagulants (DOACs), including apixaban, were associated with a lower risk of ischemic stroke compared to warfarin in patients with AF and aortic stenosis, while bleeding and mortality did not differ between DOACs and warfarin 5.
- The ARISTOTLE Trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) found that apixaban reduced the risk of major hemorrhage among patients with atrial fibrillation compared to warfarin 3.
- The presence of atrial fibrillation (AF) at discharge in patients with intermediate surgical risk aortic stenosis was associated with worse outcomes, including increased all-cause mortality at 2-year follow-up 6.
Safety and Efficacy of Apixaban
- The safety and efficacy of apixaban in patients with AF and severe aortic stenosis are influenced by various factors, including the patient's underlying condition, concomitant medications, and the presence of other comorbidities 3, 4, 5.
- Apixaban has been shown to reduce the risk of major hemorrhage and ischemic stroke in patients with AF, but its use in patients with severe aortic stenosis requires careful consideration of the potential benefits and risks 3, 4, 5.
- Further studies are needed to fully understand the safety and efficacy of apixaban in patients with AF and severe aortic stenosis, particularly in the context of transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (AVR) 2, 6.