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Updated: Jan 20, 2026
Robotic Ablation of Atrial Fibrillation
Published on: May 29, 2015
Clinical Impact of Switching From or Persisting With Rivaroxaban or Apixaban After a Bleeding Event: A Real-World
Gregory Y H Lip1,2,3, Dong Cheng4, Jenny Jiang4
1Liverpool Centre for Cardiovascular Science at University of Liverpool Liverpool John Moores University and Liverpool Heart & Chest Hospital Liverpool United Kingdom.
Insights
Switching direct oral anticoagulants (DOACs) after a bleeding event in atrial fibrillation patients impacts outcomes. Apixaban-to-rivaroxaban switchers had higher major bleeding risk, while rivaroxaban-to-apixaban switchers had lower risk.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Direct oral anticoagulants (DOACs) are used for stroke prevention in atrial fibrillation.
- Real-world data show varying DOAC effectiveness and safety.
- Outcomes after DOAC-related bleeding in atrial fibrillation are not well understood.
Purpose of the Study:
- To compare outcomes of persisting with a DOAC versus switching to another DOAC after a bleeding event in atrial fibrillation patients.
- To analyze the impact of DOAC choice on major bleeding and stroke/systemic embolism risks.
Main Methods:
- Retrospective observational study using US claims data (2012-2024).
- Included adults with nonvalvular atrial fibrillation who initiated a DOAC and experienced bleeding.
- Propensity score matching compared patients who persisted with their DOAC versus those who switched.
Main Results:
- Apixaban-to-rivaroxaban switchers (n=408) vs. apixaban persistors (n=2040) showed higher major bleeding risk (HR 1.69) and similar stroke risk.
- Rivaroxaban-to-apixaban switchers (n=901) vs. rivaroxaban persistors (n=4505) showed lower major bleeding risk (HR 0.65) and similar stroke risk.
Conclusions:
- DOAC selection after a bleeding event influences patient outcomes.
- Switching from rivaroxaban to apixaban may reduce major bleeding risk.
- Switching from apixaban to rivaroxaban may increase major bleeding risk.
Background:
Real-world research has identified differences in effectiveness and safety between direct oral anticoagulants (DOACs) when used to reduce risks of stroke and systemic embolism in patients with atrial fibrillation. However, treatment decisions and subsequent outcomes are poorly understood in patients with atrial fibrillation who experience bleeding when receiving a DOAC.
Methods:
A retrospective observational study was conducted using US claims data from Optum's Clinformatics Data Mart Database (January 2012 through March 2024). The study population comprised adults with nonvalvular atrial fibrillation who initiated a DOAC and had a subsequent claim for bleeding. After propensity score matching, patients who persisted with the same DOAC after bleeding were compared with those who switched to another DOAC. The main outcomes were major bleeding and stroke/systemic embolism.
Results:
Among 59 620 apixaban initiators and 21 004 rivaroxaban initiators with bleeding while on therapy, 408 apixaban-to-rivaroxaban switchers were matched with 2040 persistent apixaban users, and 901 rivaroxaban-to-apixaban switchers were matched with 4505 persistent rivaroxaban users. Compared with persisting with apixaban following a bleeding event, apixaban-to-rivaroxaban switching was associated with a higher risk of major bleeding (hazard ratio [HR], 1.690 [95% CI, 1.130-2.527]) and a similar risk of stroke/systemic embolism (HR, 1.793 [95% CI, 0.765-4.202]). Compared with persisting with rivaroxaban, rivaroxaban-to-apixaban switching was associated with a lower risk of major bleeding (HR, 0.651 [95% CI, 0.460-0.920]) and a similar risk of stroke/systemic embolism (HR, 0.783 [95% CI, 0.371-1.652]).
Conclusions:
These findings suggest that the choice of DOAC after a bleeding event can affect treatment outcomes in patients with atrial fibrillation.
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