The Role of Direct Oral Anticoagulants in Patients With Coronary Artery Disease
Ricky D Turgeon1, Margaret L Ackman2, Hazal E Babadagli2
1Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
Insights
Direct oral anticoagulants (DOACs) show varied results in coronary artery disease (CAD) management. Low-dose rivaroxaban may reduce thrombotic events in acute coronary syndrome (ACS) and stable CAD, but bleeding risk increases.
Area of Science:
- Cardiology
- Pharmacology
- Thrombosis Research
Background:
- Patients with coronary artery disease (CAD) face persistent high risk of thrombotic events despite current treatments.
- Direct oral anticoagulants (DOACs) have been investigated in various CAD patient populations, including those with acute coronary syndrome (ACS) and stable CAD, and those with atrial fibrillation.
Purpose of the Study:
- To evaluate the efficacy and safety of DOACs in patients with CAD across different clinical scenarios.
- To compare DOACs with standard therapies in CAD management regarding thrombotic events and bleeding risk.
Main Methods:
- Review of randomized controlled trials assessing DOACs (apixaban, dabigatran, rivaroxaban) in patients with ACS, stable CAD, and atrial fibrillation.
- Analysis of outcomes including thrombotic events, all-cause mortality, and bleeding risk.
Main Results:
- Apixaban and dabigatran showed no benefit in ACS patients, with increased bleeding.
- Reduced-dose rivaroxaban (2.5 mg BID) decreased thrombotic events and mortality in ACS when added to dual antiplatelet therapy (DAPT).
- Low-dose rivaroxaban with aspirin reduced thrombotic events in stable CAD but increased major bleeding.
- DOACs in atrial fibrillation patients undergoing PCI showed reduced bleeding with dual-pathway or low-dose triple therapy compared to warfarin, but antithrombotic efficacy is uncertain.
Conclusions:
- DOACs offer potential benefits in specific CAD settings, notably low-dose rivaroxaban in ACS and stable CAD.
- Increased bleeding risk is a significant concern when combining DOACs with antiplatelet therapy.
- Careful patient selection and adherence to trial protocols are crucial for optimizing the net benefit of DOAC-based regimens in CAD.
Abstract:
Despite contemporary management, patients with coronary artery disease (CAD) remain at high risk for thrombotic events. Several randomized controlled trials have evaluated the use of direct oral anticoagulants (DOACs) in patients with CAD, including in the setting of acute coronary syndrome (ACS) and stable CAD, and in patients with concomitant atrial fibrillation. Trials of apixaban and dabigatran in patients with ACS demonstrate no benefit with an increased risk of bleeding. Conversely, rivaroxaban at a reduced dose of 2.5 mg twice daily reduced thrombotic events and all-cause mortality when added to dual antiplatelet therapy in patients with ACS. Similarly, the addition of low-dose rivaroxaban to acetylsalicylic acid reduced the risk of thrombotic events in patients with stable CAD. However, the addition of a DOAC to antiplatelet therapy increased the risk of major bleeding. In patients with atrial fibrillation undergoing percutaneous coronary intervention, dual-pathway or low-dose triple therapy regimens including dabigatran or rivaroxaban reduced bleeding risk compared to traditional warfarin-based triple therapy, although it remains unclear whether these regimens preserve antithrombotic efficacy. DOAC-based antithrombotic regimens prove useful in patients with CAD in various settings; however, careful selection of patients and regimens per trial protocols are critical to achieving net benefit.
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