Is it acceptable to continue apixaban (Apixaban) for atrial fibrillation (AFib) with dual antiplatelet therapy following a non-ST-elevation myocardial infarction (NSTEMI)?

From the Guidelines

Continuing apixaban for atrial fibrillation while on dual antiplatelet therapy (DAPT) following a non-ST elevation myocardial infarction (NSTEMI) should be limited to the shortest duration necessary, typically up to 6 months, due to increased bleeding risk, as recommended by the 2020 ESC guidelines 1. When considering the management of antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention or medical management, the guidelines suggest a preference for a non-vitamin K antagonist oral anticoagulant (NOAC) over a vitamin K antagonist (VKA) for the default strategy and in all other scenarios if no contraindications exist.

• The recommended doses for NOACs are as follows:
  • Apixaban 5 mg twice daily
  • Dabigatran 110 mg or 150 mg twice daily
  • Edoxaban 60 mg daily
  • Rivaroxaban 15 mg or 20 mg daily
• For patients with renal failure, NOAC dose reductions are recommended, and may be considered in patients with Academic Research Consortium High Bleeding Risk (ARC-HBR) 1. The AUGUSTUS trial, a randomized controlled trial, demonstrated that apixaban significantly reduced bleeding events and death or hospitalization compared to VKA in patients with atrial fibrillation and acute coronary syndrome or PCI 1.
• The study found that apixaban plus a single antiplatelet agent (either clopidogrel, ticagrelor, or prasugrel) had a lower risk of major or clinically relevant non-major bleeding compared to triple therapy with VKA, aspirin, and a single antiplatelet agent.
• The decision to continue apixaban with DAPT should be individualized based on the patient's specific thrombotic and bleeding risks, with regular monitoring for bleeding complications and consideration of gastric protection with a proton pump inhibitor to reduce gastrointestinal bleeding risk. The use of apixaban with DAPT for more than 6 months may be considered in selected patients with high ischemic risk, but the benefits and risks should be carefully weighed, and the patient should be closely monitored for bleeding complications 1.

From the Research

Anticoagulation Therapy for AFib with Dual Antiplatelet Following NSTEMI

• The use of anticoagulation therapy in patients with atrial fibrillation (AFib) and non-ST-elevation myocardial infarction (NSTEMI) is a complex issue, with limited comparative outcome data available 2.
• A study published in the American Heart Journal found that the use of triple therapy (dual antiplatelet therapy + warfarin) in patients with AFib and NSTEMI was associated with a similar risk of major cardiac events, but a trend toward increased risk of readmission for bleeding, compared to dual antiplatelet therapy alone 2.
• A more recent narrative review published in the Expert Review of Cardiovascular Therapy suggests that anticoagulation may be an important part of the longer-term antithrombotic strategy in patients with NSTEMI and AFib, and recommends the use of triple antithrombotic therapy (anticoagulant + aspirin + clopidogrel) for up to 1 month, followed by anticoagulant + clopidogrel for up to 1 year, and then anticoagulant monotherapy thereafter 3.
• Another study published in Angiology found that revascularization (by percutaneous coronary intervention or coronary artery bypass graft) was associated with increased survival in patients with AFib and NSTEMI, and that the use of anticoagulation therapy was not significantly associated with improved outcomes 4.
• The use of direct oral anticoagulants (DOACs) such as apixaban in patients with AFib and NSTEMI has not been specifically studied in the provided evidence, but the narrative review published in the Expert Review of Cardiovascular Therapy suggests that DOACs may be preferred over warfarin due to their more predictable pharmacokinetics and lower risk of bleeding 3.
• Overall, the available evidence suggests that the use of anticoagulation therapy in patients with AFib and NSTEMI should be individualized, taking into account the patient's underlying risk factors and the potential benefits and risks of different antithrombotic regimens 2, 3, 4.