A large population-based study of patients with atrial fibrillation (AF) and valvular heart disease (VHD) found that use of apixaban was associated with a lower rate of ischemic stroke or systemic embolism and a lower rate of intracranial or gastrointestinal (GI) bleeding compared with rivaroxaban. The authors say clinicians should consider these findings when selecting anticoagulants in this patient population. The study is published in Annals of Internal Medicine.

VHD is common among patients with AF. The presence of VHD increases the risk for death, major adverse cardiovascular events, and major bleeding. Despite the common use of apixaban and rivaroxaban in this population, direct comparisons are lacking.

Researchers from the Perelman School of Medicine, University of Pennsylvania studied data from a large commercial health insurance database from January 2013 to December 2020 to emulate a target trial of effectiveness and safety of apixaban and rivaroxaban in patients with AF and VHD.

Of the 33,907 patients included in the study, 23,712 took apixaban for the first time and 10,195 were treated with rivaroxaban. In the propensity score–matched sample of patients with AF and VHD, the incidence rate of ischemic stroke or systemic embolism per 1,000 person-years of follow-up was 5.2 among apixaban users and 9.1 among rivaroxaban users.

The incidence rate of GI or intracranial bleeding per 1,000 person-years of follow-up was 14.3 among apixaban users and 28.1 among rivaroxaban users. There was no statistically significant difference in all-cause mortality between the two groups.

Since there are no direct, randomized comparisons of apixaban and rivaroxaban in patients with both AF and VHD, these findings have important clinical implications for patients.