Antithrombotic Therapy in AF and ACS by eGFR

Quick Takes

  • Apixaban was favorable to VKA for patients with AF and PCI across a wide range of renal function.
  • Aspirin was associated with more bleeding than placebo for patients with AF and PCI independent of baseline renal function.

Study Questions:

What is the risk-benefit balance of antithrombotic therapy following percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF) according to kidney function?


Among the 4,456 patients enrolled in the AUGUSTUS trial, the CKD-EPI formula was used to calculate baseline estimated glomerular filtration rate (eGFR). Using a Cox model, the authors explored the effect of apixaban versus vitamin K antagonists (VKAs) and aspirin versus placebo across categories of renal function. The primary outcome was International Society on Thrombosis and Haemostasis (ISTH) major or clinically relevant non-major bleeding. Secondary outcomes included death or hospitalization and ischemic events (e.g., death, stroke, myocardial infarction, stent thrombosis, or urgent revascularization). Creatinine clearance <30 ml/min was an exclusion in the AUGUSTUS trial.


Overall, 30%, 52%, and 19% of patients had an eGFR of >80, >50-80, and 30-50 ml/min/1.72 m2, respectively. During 6 months of follow-up, the primary outcome occurred 543 times, while death or hospitalization occurred 1,125 times and ischemic events occurred 282 times. Compared with VKA, patients assigned to apixaban had lower rates of all three outcomes across most eGFR categories without a significant interaction. The absolute risk reduction was most notable for patients with eGFR 30-50 ml/min/1.72 m2 and the outcome of bleeding (13.1% vs. 21.3%; hazard ratio, 0.59; 95% confidence interval, 0.41-0.84). Patients assigned to aspirin had higher risks of bleeding in all eGFR categories.


The authors concluded that the safety and efficacy of apixaban was consistent across a wide range of renal function when compared to VKA. The authors also concluded that the risk of bleeding with aspirin versus placebo was consistently higher across all categories of renal function.


From the primary AUGUSTUS trial, apixaban therapy was preferable to VKA therapy and placebo preferable to aspirin for reducing bleeding without increasing thromboembolic events for patients with AF who undergo PCI. This post hoc analysis demonstrated similarly favorable results across the entire range of renal function that was included in the trial. These results are not surprising, given prior studies demonstrating safety and efficacy of apixaban across a broad range of renal function categories. It should be noted that patients with severe renal dysfunction (creatinine clearance <30 ml/min) were excluded from the trial. Although apixaban has a Food and Drug Association approval for use in patients with AF on dialysis, the results of this study may not be applicable to that specific population.

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

Keywords: Acute Coronary Syndrome, Anticoagulants, Aspirin, Atrial Fibrillation, Fibrinolytic Agents, Glomerular Filtration Rate, Kidney Diseases, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Pharmaceutical Preparations, Renal Dialysis, Renal Insufficiency, Chronic, Stents, Thrombosis, Vascular Diseases, Vitamin K

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