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Comparative Study
. 2024 Dec;21(12):2397-2406.
doi: 10.1016/j.hrthm.2024.06.010. Epub 2024 Jun 13.

Comparative effectiveness and safety of apixaban and rivaroxaban in older patients with atrial fibrillation: A population-based cohort study

Mohammed Shurrab  1 , Peter C Austin  2 , Cynthia A Jackevicius  3 , Karen Tu  4 , Feng Qiu  5 , Olivia Haldenby  5 , Allan Middleton  6 , Mintu P Turakhia  7 , Renato D Lopes  8 , William E Boden  9 , Lana A Castellucci  10 , Paul A Heidenreich  11 , Jeff S Healey  12 , Dennis T Ko  13
Affiliations
Comparative Study

Comparative effectiveness and safety of apixaban and rivaroxaban in older patients with atrial fibrillation: A population-based cohort study

Mohammed Shurrab et al. Heart Rhythm. 2024 Dec.

Abstract

Background: There are no clinical trials with a head-to-head comparison between the 2 most commonly used oral anticoagulants (apixaban and rivaroxaban) in patients with atrial fibrillation (AF). The comparative efficacy and safety between these drugs remain unclear, especially in older patients who are at the highest risk for stroke and bleeding.

Objective: The purpose of this study was to compare the risk of major bleeding and thromboembolic events between apixaban and rivaroxaban in older patients with AF.

Methods: We conducted a population-based retrospective cohort study of all adult patients (66 years or older) with AF in Ontario, Canada, who were treated with apixaban or rivaroxaban between April 1, 2011, and March 31, 2020. The primary safety outcome was major bleeding, and the primary efficacy outcome was thromboembolic events. Secondary outcomes included any bleeding. Rates and hazard ratios (HRs) were adjusted for baseline comorbidities with inverse probability of treatment weighting.

Results: This study included 42,617 patients with AF treated with apixaban and 30,725 patients treated with rivaroxaban. After inverse probability of treatment weighting using the propensity score, patients in the apixaban and rivaroxaban groups were well balanced for baseline values of demographic characteristics, comorbidities, and medications; both groups had a similar mean age of 77.4 years, and 49.9% were female. At 1 year, the apixaban group had a lower risk for both major bleeding with an absolute risk reduction at 1 year of 1.1% (2.1% vs 3.2%; HR 0.65; 95% confidence interval [CI] 0.59-0.71]) and any bleeding (8.1% vs 10.9%; HR 0.73; 95% CI 0.69-0.77), with no difference in the risk for thromboembolic events (2.2% vs 2.2%; HR 1.02; 95% CI 0.92-1.13).

Conclusion: In patients with AF, 66 years or older, treatment with apixaban was associated with lower risk for major bleeding, with no difference in the risk for thromboembolic events compared with rivaroxaban.

Keywords: Anticoagulant; Apixaban; Atrial fibrillation; Bleeding; Rivaroxaban; Stroke.

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Conflict of interest statement

Disclosures Dr Shurrab is supported by a Research Chair in Cardiovascular Health, Health Sciences North Research Institute, Sudbury, Ontario. Dr Tu is supported by the Chair in Family and Community Medicine Research in Primary Care at UHN Department of Family and Community Medicine and receives a Research Scholar Award from the Department of Family and Community Medicine at the University of Toronto. Dr Turakhia has received research grants from Bristol Myers Squibb, American Heart Association, Bayer, Gilead Sciences, and the Food and Drug Administration and consulting fees from Medtronic, Pfizer, Johnson & Johnson, and AliveCor. He owns equity in iRhythm, Connect America, Forward, Evidently, and PocketRN. Dr Turakhia is an employee of iRhythm Technologies Inc., which manufactures ambulatory electrocardiogram monitors, but this work was not supported by the company and was performed exclusively in his academic role. Dr Lopes has received research grants or contracts from Amgen, Bristol Myers Squibb, GlaxoSmithKline, Medtronic, Pfizer, and Sanofi-Aventis as well as funding for educational activities or lectures from Pfizer, Bristol Myers Squibb, Novo Nordisk, and AstraZeneca and funding for consulting from Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Novo Nordisk, and AstraZeneca. Dr Castellucci’s research institution has received honoraria from Bayer, Bristol Myers Squibb–Pfizer Alliance, the ACADEMY for Continued Advancement in Healthcare Education, Amag Pharmaceutical, LEO Pharma, Sanofi, Valeo Pharma, and Servier. Dr Ko is supported by the Jack Tu Chair in Cardiovascular Outcomes Research, Sunnybrook Hospital, and the University of Toronto. The remaining authors have nothing to disclose.

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