Abstract 11994: Reduced versus Standard Dose Apixaban in Patients With Atrial Fibrillation and Acute Coronary Syndrome and/or Undergoing Percutaneous Coronary Intervention: Insights From the AUGUSTUS Trial

Background: Patients in AUGUSTUS (n=4614) taking apixaban without aspirin had less bleeding and fewer hospitalizations with no significant increase in ischemic events than those taking VKA, aspirin, or both. It is safe and efficacious to reduce apixaban from 5 mg to 2.5 mg twice daily in patients with AF and ≥2 of the following: age ≥80 years, weight ≤60 kg, serum creatinine ≥1.5 mg/dL. Data on reduced versus standard dose apixaban in patients with AF and ACS and/or PCI are limited. Methods: We assessed how many patients receiving apixaban 2.5 mg met the dose reduction criteria. We compared major or CRNM bleeding, death or rehospitalization, and death or ischemic events in those who appropriately received 2.5 mg apixaban, inappropriately received 2.5 mg apixaban, and appropriately received 5 mg apixaban. We determined the association of apixaban versus warfarin on bleeding and ischemic events in patients appropriately assigned 2.5 mg apixaban and appropriately assigned 5 mg apixaban. Results: Of 2290 patients assigned apixaban, 229 received 2.5 mg and 98 (43%) of those met reduced dose criteria. Rates of major/CRNM bleeding, death or rehospitalization, and death or ischemic events were higher in patients appropriately receiving 2.5 mg apixaban (13.7%, 34.7%, 12.2%) compared with those inappropriately receiving 2.5 mg apixaban (10.5%, 32.5%, 12.3%) and appropriately receiving 5 mg apixaban (11.0%, 23.0%, 5.7%). Compared with VKA, 2.5 mg apixaban, when used appropriately, resulted in similar or greater benefits than 5 mg apixaban for major/CRNM bleeding, death or rehospitalization, and death or ischemic events (Table). Conclusion: Of those in AUGUSTUS who received 2.5 mg apixaban, fewer than half met the reduced dose criteria. In patients with AF and recent ACS or PCI, appropriate use of reduced dose apixaban was associated with a lower risk of bleeding and similar rates of rehospitalization and ischemic outcomes compared with VKA, similar to that for standard dose apixaban.