Apixaban, Warfarin Equally Safe, Study Finds

The anticoagulants apixaban (Eliquis) and warfarin (Coumadin) are equally safe for use during catheter ablation of atrial fibrillation, a new study says.

The results of the AXAFA-AFNET 5 trial, the first randomized trial to examine whether continuous apixaban is a safe alternative to a vitamin K antagonist (VKA) during catheter ablation of atrial fibrillation, were presented at EHRA 2018, a European Society of Cardiology (ESC) congress, and published in European Heart Journal.

Researchers found similar rates of stroke and bleeding during catheter ablation of atrial fibrillation, and for the first time, an improvement in cognitive function was also seen, according to an ESC statement. “The results show that apixaban is a safe alternative to warfarin during catheter ablation of atrial fibrillation in patients at risk of stroke,” says Paulus Kirchhof, MD, international chief investigator of the trial, as well as a professor and deputy director of the Institute of Cardiovascular Sciences at the University of Birmingham, England.

ESC guidelines recommend non-vitamin K antagonist oral anticoagulants (NOACs) in preference to vitamin K antagonists (VKAs) such as warfarin, except in patients with a mechanical heart valve or rheumatic mitral valve stenosis. Unlike VKAs, NOACs do not require frequent monitoring and dose adjustment, and they reduce long-term rates of stroke and death compared to VKAs, according to ESC.

Catheter ablation is used in patients with atrial fibrillation to restore and maintain normal cardiac rhythm, but the procedure has an inherent risk of stroke, bleeding, acute brain lesions, and potential cognitive impairment. “ESC guidelines recommend that patients continue taking their prescribed NOAC or VKA during the procedure. The results of this study confirm that the NOAC apixaban is as safe as a VKA in this situation,” the organization states.

In the trial, 633 patients with atrial fibrillation and additional stroke risk factors scheduled to undergo atrial fibrillation ablation in Europe and the United States were randomized to receive either continuous apixaban or the locally-used VKA (warfarin, phenprocoumon, acenocoumarol, or fluindione).

The primary a composite of death, stroke, or bleeding, which occurred equally in 22 patients randomized to apixaban and 23 randomized to VKA. Acute small brain lesions were found in a similar number of patients in each arm.

The researchers also assessed cognitive function at the beginning and end of the trial and found that it improved equally in both treatment groups. “This is the first randomized trial to show that cognitive function is improving after atrial fibrillation ablation. It is possible that this is due to continuous anticoagulation, although we did not test this specifically,” Kirchhof says.