Apixaban: An Alternative for Patients with Atrial Fibrillation Undergoing TAVR?

Courtesy of Dr. Carlos Fava.

The prevalence of atrial fibrillation in patients undergoing transcatheter aortic valve replacement (TAVR) is high (32.9%, according to the PARTNER Trial, and 46.8%, according to the CoreValve High-Risk Study), and is associated with thromboembolic events (as in all other populations).

Apixaban has shown to benefit patients with nonvalvular atrial fibrillation, but its effects have not been studied in patients undergoing TAVR.

This study enrolled 617 patients; 345 (55.9%) of them presented sinus rhythm (SR) and 272 (44.1%) were in atrial fibrillation.

Patients with atrial fibrillation were older, presented more comorbidities and a higher Society of Thoracic Surgeons (STS) score, as well as higher risk for stroke and for bleeding.

At 30 days, the safety endpoint (Valve Academic Research Consortium–2 [VARC-2] criteria) was more frequent in patients with atrial fibrillation (23.2% vs. 11%; p <0.01). They also presented more frequent occurrences of life-threatening bleeding and renal insufficiency.

The rates for cardiac death and all-cause death after the first 30 days and at 1 year were lower in patients with RS (21.7% vs 10.1%; p <0.01).

Among patients with atrial fibrillation, 141 were treated with apixaban and 131 received a vitamin K antagonist. The safety endpoint at 30 days was lower in patients receiving apixaban (13.5% vs. 30.5%; p <0.01), with a lower rate of life-threatening bleeding (3.5% vs. 5.3%; p <0.01), and a non-significant numerical difference in favor of apixaban as regards stroke (2.1 vs. 5.3%; p = 0.17).

Conclusion

In patients undergoing TAVR, atrial fibrillation is associated with a significantly higher rate of all-cause mortality at 12 months. The safety endpoint in patients with atrial fibrillation who were anticoagulated with apixaban was significantly less frequent when compared with patients receiving vitamin K antagonists.

Editorial

The presence of atrial fibrillation is frequent in high-risk patients undergoing TAVR; the rate of new atrial fibrillation is 7% and is associated with negative impact at 1 year.

The development of new anticoagulant agents has proven to be beneficial for patients with nonvalvular atrial fibrillation, but not in cases of valve replacement.

Courtesy of Dr. Carlos Fava. Buenos Aires Favaloro Foundation, Argentina.

Original title: Apixaban in Patients with Atrial Fibrillation After Transfemoral Aortic Valve Replacement.

Reference: Julia Seeger et al.  J Am Coll Cardiol Intv 2017;10:66-74.

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