Apixaban Enhances Endogenous Fibrinolysis in Patients with Atrial Fibrillation

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.AIMS: Approximately 20% of ischaemic stroke patients exhibit spontaneous arterial recanalization, attributable to endogenous fibrinolysis, which strongly relates to improved functional outcome. The impact of oral anticoagulants on endogenous fibrinolysis is unknown. Our aim was to test the hypothesis that apixaban enhances endogenous fibrinolysis in non-valvular atrial fibrillation (NVAF). METHODS AND RESULTS: In a prospective cross-sectional analysis, we compared endogenous fibrinolysis in NVAF patients (n = 180) taking aspirin, warfarin, or apixaban. In a prospective longitudinal study, patients were tested before and after apixaban (n = 80). Endogenous fibrinolysis was assessed using the Global Thrombosis Test (GTT) and thromboelastography (TEG). Endogenous fibrinolysis [measured by GTT lysis time (LT)] was shorter on apixaban compared with warfarin or aspirin [median 1850 (IQR 1591-2300) vs. 2758 (2014-3502) vs. 2135 (1752-2463) s, P < 0.0001]. Among TEG indices, a small but significant difference in clot lysis time (CLT) was observed [apixaban 60.0 (45.0-61.0) vs. warfarin 61.0 (57.0-62.0) vs. aspirin 61.0 (59.0-61.0) min, P = 0.036]. Apixaban improved endogenous fibrinolysis measured using the GTT [LT pre-treatment 2204 (1779-2738) vs. on-treatment 1882 (1607-2374) s, P = 0.0003], but not by using TEG. Change in LT (ΔLT) with apixaban correlated with baseline LT (r = 0.77, P < 0.0001). There was weak correlation between ΔLT and ΔCLT in response to apixaban (r = 0.28, P = 0.02) and between on-apixaban LT and CLT (r = 0.25, P = 0.022). CONCLUSION: Apixaban enhances endogenous fibrinolysis, with maximal effect in those with impaired fibrinolysis pre-treatment. Apixaban-treated patients exhibit more favourable fibrinolysis profiles than those taking warfarin or aspirin. Whether apixaban may confer additional thrombotic risk reduction in NVAF patients with impaired fibrinolysis, compared to warfarin, merits further study.Peer reviewedFinal Accepted Versio

Hypertension and atrial fibrillation: Closing a virtuous circle.

Ying Gue and Gregory Lip discuss the accompanying study by Ana-Catarina Pinho-Gomes and co-workers on blood pressure lowering treatment in patients with atrial fibrillation

Antithrombotic in atrial fibrillation and coronary artery disease – Does less mean more?

© 2022 American Medical Association. All Rights Reserved. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1001/jamacardio.2022.1572In the treatment of patients with chronic coronary syndrome, the use of antiplatelets in the form of aspirin is a class 1 indication in the prevention of future thrombotic events.1 Similarly, oral anticoagulation (OAC) has a class 1 indication for patients with atrial fibrillation (AF) and a CHA2DS2-VASc (congestive heart failure) score of 2 or more in males and a score of 3 or more in females in the form of a non–vitamin K antagonist oral anticoagulant (NOAC) for stroke prevention.2 However, the optimal choice of long-term antithrombotic therapy in patients with AF in the presence of coronary artery disease (CAD) has been subject to much debate. Striking the right balance between thrombotic and bleeding risk with different monotherapy or combination therapy with OAC and antiplatelet(s) remains a difficult task requiring the understanding of the dynamic nature and continual assessment of nonmodifiable and modifiable bleeding and thrombotic risk factors.Peer reviewe

Thrombotic Profile and Oral Anticoagulation in Asian and Non-Asian Patients With Nonvalvular Atrial Fibrillation

© 2019 American College of Cardiology Foundation, Published by Elsevier.Peer reviewedFinal Accepted Versio