Article, 2024

Apixaban vs Aspirin According to CHADS-VASc Score in Subclinical Atrial Fibrillation: Insights From ARTESiA

Journal of the American College of Cardiology, ISSN 0735-1097, Volume 84, 4, Pages 354-364, 10.1016/j.jacc.2024.05.002

Contributors

Lopes R.D. 0000-0003-2999-4961 (Corresponding author) [1] Granger C.B. [1] Wojdyla D.M. [1] McIntyre W.F. 0000-0001-6082-7542 [2] Alings M. 0000-0003-2090-4683 [3] Mani T. [2] Ramasundarahettige C. [2] Rivard L. [4] Atar D. 0000-0003-1513-8793 [5] Birnie D.H. [6] Boriani G. 0000-0002-9820-4815 [7] Amit G. [8] Leong-Sit P. [9] Rinne C. Duray G.Z. [10] Gold M.R. 0000-0002-4579-0216 [11] Hohnloser S.H. 0000-0001-5030-3315 [12] Kutyifa V. 0000-0002-0016-289X [13] Benezet-Mazuecos J. Cosedis Nielsen J. [14] Sticherling C. 0000-0001-8428-7050 [15] Benz A.P. [2] [16] Linde C. 0000-0002-9039-6023 [17] Kautzner J. [18] Mabo P. [19] Mairesse G. 0000-0002-2255-4181 [20] Connolly S.J. 0000-0002-7377-335X [2] Healey J.S. 0000-0003-1216-7580 [2]

Affiliations

  1. [1] Duke Clinical Research Institute
    2. [NORA names: United States; America, North; OECD];
  2. [2] Population Health Research Institute
    3. [NORA names: Canada; America, North; OECD];
  3. [3] Amphia Hospital
    4. [NORA names: Netherlands; Europe, EU; OECD];
  4. [4] Montreal Heart Institute
    5. [NORA names: Canada; America, North; OECD];
  5. [5] Ullevål University Hospital
    6. [NORA names: Norway; Europe, Non-EU; Nordic; OECD];

Abstract

Background: ARTESiA (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation) demonstrated that apixaban, compared with aspirin, significantly reduced stroke and systemic embolism (SE) but increased major bleeding in patients with subclinical atrial fibrillation. Objectives: To help inform decision making, the authors evaluated the efficacy and safety of apixaban according to baseline CHADS-VASc score. Methods: We performed a subgroup analysis according to baseline CHADS-VASc score and assessed both the relative and absolute differences in stroke/SE and major bleeding. Results: Baseline CHADS-VASc scores were <4 in 1,578 (39.4%) patients, 4 in 1,349 (33.6%), and >4 in 1,085 (27.0%). For patients with CHADS-VASc >4, the rate of stroke was 0.98%/year with apixaban and 2.25%/year with aspirin; compared with aspirin, apixaban prevented 1.28 (95% CI: 0.43-2.12) strokes/SE per 100 patient-years and caused 0.68 (95% CI: −0.23 to 1.57) major bleeds. For CHADS-VASc <4, the stroke/SE rate was 0.85%/year with apixaban and 0.97%/year with aspirin. Apixaban prevented 0.12 (95% CI: −0.38 to 0.62) strokes/SE per 100 patient-years and caused 0.33 (95% CI: −0.27 to 0.92) major bleeds. For patients with CHADS-VASc =4, apixaban prevented 0.32 (95% CI: −0.16 to 0.79) strokes/SE per 100 patient-years and caused 0.28 (95% CI: −0.30 to 0.86) major bleeds. Conclusions: One in 4 patients in ARTESiA with subclinical atrial fibrillation had a CHADS-VASc score >4 and a stroke/SE risk of 2.2% per year. For these patients, the benefits of treatment with apixaban in preventing stroke/SE are greater than the risks. The opposite is true for patients with CHADS-VASc score <4. A substantial intermediate group (CHADS-VASc =4) exists in which patient preferences will inform treatment decisions. (Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation; NCT01938248)

Keywords

CHADS-VASc score, apixaban, aspirin, major bleeding, stroke/systemic embolism, subclinical atrial fibrillation

Data Provider: Elsevier

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