Apixaban Superior to Rivaroxaban in Patients With AF and Valvular Heart Disease

Apixaban demonstrated increased efficacy and safety compared with rivaroxaban when used for anticoagulation in patients with atrial fibrillation (AF) or valvular heart disease (VHD), according to study findings published in the Annals of Internal Medicine.

Among patients with VHD, AF is a common occurrence. Both AF and VHD increase the risk for death, major cardiovascular events such as ischemic stroke and systemic embolisms, and major bleeding episodes. Oral anticoagulants such as apixaban and rivaroxaban are often prophylactically used in patients with AF and VHD.

Researchers conducted a new-user, active comparator, cohort study. They assessed whether 19,894 new users of either apixaban or rivaroxaban with diagnoses of either AF (n=9947) or VHD (n=9947) demonstrated an increased combined risk for ischemic stroke or systemic embolisms or bleeding.

They obtained relevant data on patients across the United States from Optum’s commercial health insurance database between January 1, 2013 and December 31, 2020. They analyzed patients who received each drug at the full dose and those who received reduced doses (5 mg and 2.5 mg of apixaban daily vs. 20 mg and 15 mg of rivaroxaban daily).

The researchers found that patients with AF or VHD taking apixaban demonstrated lower incidence for ischemic stroke or systemic embolisms than those on rivaroxaban (hazard ratio [HR], 0.57; 95% CI, 0.40-0.80). Patients on apixaban also had lower incidence of intracranial or gastrointestinal bleeding compared with those taking rivaroxaban (HR, 0.51; 95% CI, 0.41-0.62).

A post hoc analysis was also conducted to determine all-cause mortality as a secondary outcome. Among the propensity score-matched sample of patients with both AF and VHD, 1085 died (n=587, apixaban; n=498, rivaroxaban). No significant differences in all-cause mortality between apixaban and rivaroxaban were observed among patients with both AF and VHD (HR, 1.10; 95% CI, 0.97-1.24).

The researchers acknowledged that the findings of their study have important clinical implications for patients with AF and VHD.

“Until evidence from randomized controlled trials become available, we believe clinicians should consider our findings when selecting anticoagulants in patients with AF and VHD,” they concluded.

Study limitations include the relatively short follow-up duration of the study, the assumption that filled prescriptions indicated that patients actually ingested the prescribed drug, and the researcher’s inability to determine specific types of VHD.

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.