Apixaban as part of antithrombotic therapy in patients with atrial fibrillation and ischemic heart disease: age-related characteristics and clinical benefits

The coexistence of atrial fibrillation and coronary artery disease is an adverse prognostic factor increasing the risk of prognosis determining events, including thrombosis/embolism at any location, bleeding, and ultimately death. In many cases, these risks are associated with multi-agent antithrombotic therapy, which includes (at least in the early stages of treatment) the concomitant use of an anticoagulant and two antiplatelet agents such as aspirin and a P2Y12 receptor blocker. The results of key studies of multi-agent antithrombotic therapy made it possible to develop a number of “universal” guidelines aimed primarily at reducing the risk of bleeding in this patient population. The guidelines cover the use of radial arterial (RA) access for percutaneous coronary intervention (PCI), early discontinuation of aspirin, and the preferred use of clopidogrel as a P2Y12 receptor antagonist. As for anticoagulants, the guidelines place clear focus on prescribing “full doses” of direct oral anticoagulants instead of warfarin (unless there is a direct indication for the latter). The review discusses in details issues of the choice of the most preferred oral anticoagulant in terms of its efficacy and safety, including as part of multi-agent antithrombotic therapy. Particular focus has been placed on apixaban, its use and benefits in various patient populations, including those with invasive or conservative treatment strategies, the elderly, and patients with a history of stroke and chronic kidney disease. An indirect comparison of randomized trial results and an analysis of real-world data (RWD) convincingly demonstrate the more favourable safety profile of apixaban compared to rivaroxaban and dabigatran. Apixaban is also considered a preferable choice for geriatric and advanced age patients as its benefits with regards to bleeding complications in this age group are maximal, and its efficacy is not inferior to that in younger patients.

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