Apixaban in Atrial Fibrillation
Apixaban in Atrial Fibrillation
Source: Jordan Cardiac Society Conference – October 16–17 2025
Speaker: Dr. Raed Awaisheh,Interventioal Cardiologist
Keynotes :
1. Atrial Fibrillation Overview
• AF is the most common arrhythmia, increasing stroke risk five-fold.
• Responsible for about one-third of strokes in patients ≥ 65 years.
• AF-related strokes cause higher mortality (≈ 50 % at 1 year) and greater long-term disability.
• Types:
• Valvular AF → prosthetic valve, stenosis, or regurgitation.
• Non-valvular AF (NVAF) → often due to hypertension, thyroid disease, or structural heart change.
2. Risk Stratification
• CHA₂DS₂-VASc → assesses thromboembolic risk and guides anticoagulation. CHA₂DS₂-VASc = 1 is the threshold where anticoagulation should be considered
• HAS-BLED → identifies bleeding risk factors:
H – Hypertension > 160 mmHg
A – Abnormal renal / liver function (1 point each):
• Significant Renal Impairment : renal transplant or Cr > 2.3 mg/dL
• Liver : bilirubin > AST/ALT/ALP > 3× ULN
S – Stroke history
B – Bleeding history or predisposition
L – Labile INR (< 60 % TTR)
E – Elderly > 65 years
D – Drugs (antiplatelets/NSAIDs) or alcohol > 8 units/week
Interpretation Summary
• HAS-BLED 0–1 → Low risk → standard anticoagulation
• HAS-BLED 2 → Moderate risk → proceed with caution and correct modifiable factors
• HAS-BLED ≥ 3 → High risk → intensify “monitoring” but do not withhold anticoagulation—focus on risk mitigation
3. Apixaban – Simplified Dosing Summary
• Standard dose: 5 mg twice daily for most NVAF patients.
• Reduced dose (2.5 mg twice daily): only if ≥ 2 of the following apply → age ≥ 80 y, weight ≤ 60 kg, or serum creatinine ≥ 1.5 mg/dL.
• Key point: creatinine elevation alone does not mandate dose reduction.
• Renal impairment: dosing decisions depend on age, weight, and creatinine, not kidney function alone; even in end-stage renal disease, the standard 5 mg BID remains appropriate unless ≥ 2 reduction criteria are met.
• Clinical note: Apixaban is the only DOAC approved for patients with AF on dialysis — shown to reduce both bleeding and thrombotic events compared to warfarin.
5. Evidence-Based Highlights
• Apixaban reduces stroke / systemic embolism, major bleeding, and mortality vs warfarin.
• Meta-analyses confirm superior effectiveness and safety vs other DOACs.
• Proven benefit in elderly and CKD patients with consistent outcomes across studies.
6. Key Takeaways
• Superior efficacy and safety across all patient groups.
• Only DOAC approved for ESKD on dialysis.
• Predictable dose, no INR testing, and minimal interactions → simplifies management.
• Close monitoring and correction of modifiable HAS-BLED factors remain essential for safe therapy.
