Latest news with #apixaban
Medscape
2 days ago
- Health
- Medscape
Anticoagulants in AF Post-ICH: The Dilemma Continues
TOPLINE: In patients with atrial fibrillation (AF) with a recent episode of intracranial hemorrhage (ICH), the use of oral anticoagulants significantly reduced net adverse clinical events — primarily driven by a reduced risk for ischemic stroke/systemic thromboembolism — but with an increased risk for recurrent ICH. METHODOLOGY: Oral anticoagulants prevent stroke in patients with AF, but their efficacy in those who have recently experienced an ICH remains unclear. Researchers conducted a systematic literature review through March 2025 and performed an updated meta-analysis of randomized controlled trials comparing the use of oral anticoagulants with placebo or antiplatelets in patients with nonvalvular AF after a spontaneous ICH. The analysis included 653 patients (weighted mean age, 78.2 years; 38% women; 95% White) from four trials with a low risk for bias, with follow-up durations ranging from a mean of 0.53 years to a median of 1.9 years. The primary endpoint was net adverse clinical events — a composite of ischemic stroke/systemic thromboembolism, nonfatal myocardial infarction, cardiovascular death, recurrent ICH, and extracranial major bleeding. TAKEAWAY: The breakdown of oral anticoagulants used was 65% apixaban, 15% edoxaban, 14% dabigatran, 4% rivaroxaban, and 1% warfarin. The use of oral anticoagulants reduced net adverse clinical events by 31% (relative risk [RR], 0.69; 95% CI, 0.52-0.93) and ischemic stroke/systemic thromboembolism by 76% (RR, 0.24; 95% CI, 0.09-0.61), translating into a number needed to treat of 12 and 8, respectively. However, oral anticoagulants carried a more than threefold higher risk or recurrent ICH (RR, 3.20; 95% CI, 1.30-7.85), translating to a number needed to harm of 22. There were no significant differences in fatal ischemic stroke, fatal ICH, major extracranial hemorrhage, myocardial infarction, or cardiovascular death on the basis of oral anticoagulant use. IN PRACTICE: '[This] meta-analysis informs shared decision-making between clinicians and patients, demonstrating a net clinical benefit of OACs [oral anticoagulants] predominantly through a reduction in ischemic stroke/systemic thromboembolism, while being cognizant of an increased risk of recurrent ICH,' the researchers wrote. 'The magnitude of benefit and risk may differ across ICH subtypes and with the timing of OACs initiation, warranting further investigation through [individual patient data] meta-analysis,' they further added. SOURCE: This study was led by Kuan-Yu Chi, MD, and Pei-Lun Lee, MD, of Jacobi Medical Center, Albert Einstein College of Medicine in New York City, and Yu Chang, MD, of the National Cheng Kung University in Tainan, Taiwan. It was published online on July 21, 2025, in the Journal of the American College of Cardiology. LIMITATIONS: This study lacked individual patient data, which prevented deeper analyses such as timing of events. The number of included trials and participants were insufficient to detect the effects on outcomes that occurred less frequently. All the included trials had an open-label design. DISCLOSURES: Three authors reported receiving research funding and awards from various sources including the Johns Hopkins University Claude D. Pepper Older Americans Independence Center funded by the National Institute on Aging; National Heart, Lung, and Blood Institute; and National Institutes of Health National Institute of Aging. One author reported serving as a consultant for Novo Nordisk, Merck, and HeartFlow, Inc. This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
Medscape
15-07-2025
- Health
- Medscape
APOE4 May Raise Brain Bleed Risk in Apixaban Users With AF
TOPLINE: Carriers of the apolipoprotein E epsilon 4 (APOE ε4) allele had a threefold higher risk for intracranial hemorrhage (ICH) when taking apixaban for atrial fibrillation (AF) compared with noncarriers, a new study suggested. METHODOLOGY: The study included data for more than 2000 participants (mean age, 71 years; 55% men; 84% with European ancestry) from the All of Us Research Program, collected between 2017 and 2022. The median follow-up duration was 2.9 years. Individuals older than 50 years who were taking apixaban for AF were included in the study, which excluded those with prior ischemic stroke or ICH. After APOE ε4 status was determined, carriers (n = 483) were defined as those having one or two alleles and noncarriers (n = 1555) as those without alleles. The primary outcome was incident ICH after initiating apixaban therapy, including any nontraumatic intraparenchymal, subdural, or subarachnoid hemorrhage. Secondary outcomes included incidences of intraparenchymal hemorrhage, ischemic stroke, and a composite of ischemic stroke and ICH. Also used was a HAS-BLED score, which includes factors such as age, hypertension, stroke, and history of or predisposition for bleeding, to predict risk for major bleeding. TAKEAWAY: About 26 participants developed ICH during the study, with cumulative ICH incidence significantly higher among APOE ε4 carriers than noncarriers (3.1% vs 1%; P = .007). Carrying the APOE ε4 allele was associated with a threefold increase in risk for ICH (hazard ratio [HR], 3.1; P = .004) and intraparenchymal hemorrhage (HR, 3.7; P = .002) compared with not carrying the allele. There were no significant differences between carriers and noncarriers in the other two secondary outcomes. APOE information improved the predictive power of the HAS-BLED score, with C statistics of 0.74 and 0.68 for models with and without APOE information, respectively (P = .03). IN PRACTICE: The findings 'underscore the importance of genetics in personalizing pharmacological therapy, aiding clinicians in identifying high-risk patients and tailoring anticoagulant strategies,' the investigators wrote. 'Further research is needed to evaluate whether cerebral amyloid angiopathy mediates the observed association and whether APOE ε4 information improves clinical decision-making about anticoagulation therapy' in patients with AF, they added. SOURCE: This study was led by Santiago Clocchiatti-Tuozzo, MD, Yale School of Medicine, New Haven, Connecticut. It was published online on June 23 in JAMA Neurology LIMITATIONS: This study could not distinguish between lobar and deep hemorrhages because of its reliance on electronic health record data, limiting the ability to determine the relative contributions of hypertension and cerebral amyloid angiopathy to each hemorrhage type. The predominant European ancestry of participants may have limited the generalizability of the findings. Additionally, external validation of the prediction analyses was not possible because of the lack of other genetic studies in the US evaluating patients with AF treated with apixaban. DISCLOSURES: This study was funded by the National Institutes of Health and the American Heart Association. Several investigators reported having financial ties with various organizations and companies. Full details are provided in the original article. This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
