Compared with treatments that include vitamin K antagonists (VKA), aspirin, or both, an antithrombotic regimen consisting of apixaban and a P2Y12 inhibitor without aspirin provides superior safety and similar efficacy in atrial fibrillation (AFib) patients with acute coronary syndromes (ACS), whether they are treated medically or with percutaneous coronary intervention (PCI), or undergoing elective PCI. Findings from the AUGUSTUS ACS trial were presented Sept. 26 at TCT 2019 and published in Circulation.

Stephan Windecker, MD, et al., explored bleeding, death and hospitalization, as well as death and ischemic events by antithrombotic strategy, in three prespecified subgroups: patients with ACS treated medically (n=1,097); patients with ACS treated with PCI (n=1,714); and patients undergoing elective PCI (n=1,784).

Results showed that compared with VKA, apixaban reduced ISTH major or clinically relevant nonmajor bleeding in patients across all three subgroups. It also reduced death or hospitalization in all three patient groups. Additionally, apixaban resulted in a similar effect on death and ischemic events in the ACS treated medically, ACS treated with PCI, and elective PCI groups compared with VKA. Compared with placebo, researchers noted that aspirin had a higher rate of bleeding than placebo in patients with ACS treated medically, ACS treated with PCI and elective PCI. There was no difference in outcomes among the three groups for the composite of death or hospitalization and death and ischemic events when comparing placebo with aspirin.

The trial is the only one in the field that currently includes patients with ACS managed medically. Some limitations of the study include the fact that it does not address the optimal treatment duration for the combined anticoagulation and P2Y12 antiplatelet treatment, as all patients were treated for six months. Additionally, the study authors note "it cannot be excluded that shorter durations of triple antithrombotic therapy may have led to different outcomes." That aside, they suggest their findings provide "important additional guidance on the optimal antithrombotic therapy for physicians treating patients with AFib and ACS and/or undergoing PCI." The write: "Accordingly, anticoagulation with apixaban, at the dose labeled for stroke prevention in patients with AFib, combined with a P2Y12 inhibitor without aspirin should be considered in patients with AFib and ACS, managed medically or with PCI, or those with AF undergoing elective PCI.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: TCT19, Transcatheter Cardiovascular Therapeutics, Warfarin, Atrial Fibrillation, Aspirin, Acute Coronary Syndrome, Angiography, Percutaneous Coronary Intervention

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