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Apixaban superior to VKAs for major bleeding, stroke/STE and all-cause mortality

ESC 2019
A French observational study comparing different types of non-vitamin K oral anticoagulation (NOAC) showed that 42% to 65% of patients were treated with standard doses of these agents. Analyses of standard doses confirmed the superiority of apixaban when compared to vitamin K antagonists (VKAs) for major bleeding, stroke, and all-cause mortality.

Real-world data which compares all currently available NOACs on a nationwide scale are not available. As NOACs are often underdosed in everyday practice, comparing the different agents can be rather complicated. NAXOS, a French real-world study, compared safety (major bleeding), effectiveness (stroke, systemic thromboembolic events [STE]) and all-cause mortality for the NOACs apixaban, dabigatran, rivaroxaban, and VKAs, in adult patients with non-valvular atrial fibrillation (NVAF) who initiated a given NOAC between 2014 and 2016. Analyses were performed with adjustment on propensity scores. To avoid bias potentially related to underdosing, the present analysis only includes patients who received standard doses of apixaban (5 mg BID), rivaroxaban (20 mg OD), and dabigatran (150 mg BID), or VKAs. The study included NOAC-naïve patients only. The results showed that in the NOAC-naïve cohorts, 62.3% of those receiving apixaban, 65.2% of those receiving rivaroxaban, and 42.4% of those receiving dabigatran had the standard dose at the index dispensation. A total of 112,628 patients were treated with VKAs. After propensity scores adjustment, apixaban 5 mg was associated with a lower risk of major bleeding compared with VKAs (HR 0.47) and rivaroxaban 20 mg (HR 0.64) but not with dabigatran 150 mg (HR 0.97). Apixaban was associated with a lower risk of stroke and STE in comparison with VKAs (HR 0.62), but not with rivaroxaban (HR 1.03) and dabigatran (HR 0.96). Apixaban showed a lower risk of all-cause mortality versus VKAs (HR 0.44) and rivaroxaban (HR 0.87) but not to dabigatran (HR 1.10) [1].

1. Danchin N, et al. Comparative safety and effectiveness of standard doses of apixaban versus dabigatran, rivaroxaban, and VKAs in nonvalvular atrial fibrillation patients in France: the NAXOS study. Abstract P1255. ESC Congress 2019, 31 Aug-4 Sept, Paris, France.

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