Eliquis (Apixaban) for Heart Failure
Eliquis (apixaban) is not specifically indicated for the treatment of heart failure itself, but is recommended for patients with heart failure who also have atrial fibrillation to prevent stroke and systemic embolism. 1
Role in Heart Failure Patients
Apixaban is an oral anticoagulant that has specific indications in patients with heart failure:
- Apixaban is recommended for patients with heart failure who have atrial fibrillation to prevent thromboembolism, as heart failure is considered a moderate risk factor for stroke in AF patients 2
- Heart failure patients with AF are at high risk of thromboembolic events due to low cardiac output, blood stasis in dilated cardiac chambers, poor contractility, and regional wall motion abnormalities 2
- Anticoagulation is firmly indicated in heart failure associated with atrial fibrillation (Class I, Level of Evidence A) 2
Evidence for Efficacy in Heart Failure Patients with AF
- In the ARISTOTLE trial, apixaban was superior to warfarin for reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, including those with heart failure 1
- Patients with left ventricular systolic dysfunction (with/without heart failure) had a higher risk of stroke/systemic embolism or death compared to those with heart failure but preserved LV function 3
- Apixaban reduced the risk of stroke, major bleeding, or death more than warfarin in all patient groups, including those with heart failure 3
- In a large real-world analysis, apixaban showed superior effectiveness and safety compared to vitamin K antagonists in patients with AF, heart failure, and low body weight 4
Dosing Considerations
- Standard dosing for apixaban in nonvalvular AF is 5 mg orally twice daily 1
- Reduced dosing (2.5 mg twice daily) is recommended for patients with at least 2 of the following: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 1
Important Limitations and Considerations
- Apixaban does not treat heart failure itself - it is not a heart failure medication but an anticoagulant used in heart failure patients with AF 1
- For heart failure patients without atrial fibrillation, there is insufficient evidence to support routine anticoagulation 2
- The core medications for heart failure treatment remain ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists, and diuretics 2
- In patients with heart failure and AF, rate control medications (beta-blockers, digoxin) are recommended alongside anticoagulation 2
Safety Profile in Heart Failure
- Apixaban appears to have a favorable safety profile compared to warfarin in heart failure patients 3, 4
- In a network meta-analysis, apixaban might be associated with a comparable risk of major bleeding compared to aspirin in heart failure patients, while other NOACs might have higher bleeding risk 5
- Careful monitoring is still required, particularly in patients with renal impairment, as heart failure can affect renal function 1
Common Pitfalls to Avoid
- Do not use apixaban as a treatment for heart failure itself - it only addresses the thromboembolic risk in heart failure patients with AF 1
- Avoid confusing the role of anticoagulation in heart failure - it's indicated for those with AF but not routinely recommended for those in sinus rhythm 2
- Be cautious with concomitant medications that may increase bleeding risk in patients already on apixaban 1
- Remember that heart failure itself is a risk factor for stroke in patients with AF and should be considered when assessing stroke risk 2