Inpatient Insights

Apixaban may prevent strokes in patients with subclinical AFib

Subclinical AFib, also known as atrial heart rhythm episodes, is a nonsymptomatic repetitive tachyarrhythmia that can occur most often in patients with electronic cardiac devices such as pacemakers or defibrillators. Subclinical AFib is associated with an increased risk of stroke, but treatment with oral anticoagulants is of uncertain benefit. A global group of researchers sought to determine whether apixaban would result in a lower risk of stroke or systemic embolism than aspirin among patients with subclinical AFib detected by a pacemaker, defibrillator, or implantable cardiac monitor.

The ARTESIA investigators conducted a trial involving patients with subclinical AFib lasting 6 minutes to 24 hours. Patients were randomly assigned in a double-blind, double-dummy design to receive 5 mg apixaban, a direct-acting oral anticoagulant that has been useful for stroke prevention among patients with clinical AFib,  twice daily or 81 mg aspirin daily. The trial medication was discontinued, and anticoagulation started, if subclinical AFib lasting more than 24 hours or clinical AFib developed.

The results of the study, which were published online in NEJM on November 12, 2023, indicated that after a mean follow-up of 3.5 ± 1.8 years, stroke or systemic embolism occurred in 55 patients in the apixaban group and in 86 patients in the aspirin group. In the on-treatment population, the rate of major bleeding was 1.71% per patient-year in the apixaban group and 0.94% per patient-year in the aspirin group. Fatal bleeding occurred in five patients in the apixaban group and eight patients in the aspirin group.

The authors concluded that apixaban resulted in a lower risk of stroke or systemic embolism among patients with subclinical AFib. Apixaban resulted in a lower risk of stroke or systemic embolism than aspirin but a higher risk of major bleeding. ■

Does aspirin reduce bleeding risk for patients with an LVAD?

 Although left ventricular assist devices (LVADs) greatly enhance the quality of life for patients with advanced heart failure, nonsurgical bleeding is an inherent risk factor and is the leading cause of death in this population.

To address this risk, aspirin as an antiplatelet agent is mandated along with vitamin K antagonists as antithrombotic therapy. Researchers participating in the ARIES-HM3 trial found that antithrombotic therapy without aspirin is safe and associated with a reduction of bleeding events.

The trial, a randomized, double-blind, placebo-controlled study of vitamin K antagonist therapy with and without aspirin (100 mg/day), was conducted across 51 centers in 9 countries and included 628 patients with advanced heart failure implanted with a fully magnetically levitated LVAD. The study enrolled patients from July 2020 to September 2022 with median follow-up of 14 months. The primary outcome was survival free of a major nonsurgical hemocompatibility-related adverse event (i.e., stroke, pump thrombosis, major bleeding, or arterial peripheral thromboembolism) at 12 months.

Results of the study, published online in JAMA on November 11, 2023, showed that 68.1% of patients who received aspirin reached the primary outcome, compared with 74.2% of patients who did not receive aspirin. The authors concluded that avoidance of aspirin as part of an antithrombotic regimen that included a vitamin K antagonist in patients supported with an LVAD resulted in a significant decrease (34%) in major nonsurgical bleeding events and no significant increase in thromboembolic risk. ■

Pharmacotherapy can help those with alcohol use disorder

According to the results from the 2021 National Survey on Drug Use and Health published by SAMHSA, only 265,000 (0.9%) of the approximately 29.5 million people who reported an alcohol use disorder in 2021 received pharmacotherapy. Researchers from RTI International, Kaiser Permanente, and The Ohio State University conducted a systematic review and meta-analysis to determine which pharmacotherapies are associated with improved outcomes for people with alcohol use disorder.

The study, published in the November 7, 2023, issue of JAMA, included 118 clinical trials and 20,976 participants pulled from PubMed, the Cochrane Library, the Cochrane Central Trials Registry, PsycINFO, CINAHL, and EMBASE from November 2012 to September 9, 2022, with additional relevant articles added until August 14, 2023. For evaluating efficacy outcomes, randomized clinical trials of at least 12 weeks’ duration were included, while for evaluating adverse effects, randomized clinical trials and prospective cohort studies that compared drug therapies and reported health outcomes or harms were included.

The meta-analysis showed that 50 mg/day of oral naltrexone and acamprosate were each associated with significantly improved alcohol consumption–related outcomes compared with placebo. Adverse effects included higher GI distress for acamprosate and naltrexone compared with placebo. The authors suggested that these findings support the use of oral naltrexone and acamprosate, in conjunction with psychosocial interventions, as first-line pharmacotherapies for alcohol use disorder. ■