ESC 2021: Edoxaban shown to be noninferior to warfarin for adverse events after TAVI

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George Dangas

Edoxaban is noninferior to warfarin and its analogues for adverse clinical events in patients with atrial fibrillation after transcatheter aortic valve implantation (TAVI), new research has found.

Findings of the ENVISAGE-TAVI AF study, which were published in the New England Journal of Medicine and presented at the European Society of Cardiology’s 2021 congress (ESC 2021, 27–30 August, virtual) also showed that the incidence of major bleeding was higher with edoxaban compared with vitamin K antagonists (VKAs).

Principal investigator, George Dangas of the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, USA, said: “Overall, this trial showed the noninferiority of edoxaban compared to warfarin (or similar analogues) with respect to the composite efficacy endpoint of adverse clinical events.

“On the other hand, we need to be attentive to the higher bleeding risks with edoxaban. Based on secondary analyses, it seems that lowering the edoxaban dosage when indicated and avoiding patients on mandatory antiplatelet therapy is reasonable safety advice from a clinical point of view. We will be conducting a detailed analysis on specific types of bleeding in the near future.”

Oral anticoagulation is recommended to prevent stroke in patients with atrial fibrillation but there is little information on the safety and efficacy of direct-acting oral anticoagulants (DOACs) versus VKAs after TAVI, say the researchers.

ENVISAGE-TAVI AF compared the safety and efficacy of the DOAC edoxaban with VKAs (warfarin and its analogues) in atrial fibrillation patients with an indication for oral anticoagulation after successful TAVI. The trial enrolled 1,426 patients with atrial fibrillation from 173 medical centres in 14 countries on three continents. Participants were randomly assigned to either edoxaban or the locally available VKA between 12 hours and five days after successful completion of TAVI.

The primary efficacy endpoint was a composite of adverse clinical events, including all-cause death, myocardial infarction, ischaemic stroke, systemic thromboembolism, valve thrombosis, and major bleeding according to the International Society on Thrombosis and Haemostasis (ISTH) definition. The primary safety endpoint was the incidence of major bleeding according to the ISTH definition. The average age of participants was 82 years, 47.5% were women and the average follow-up was 18 months.

Edoxaban was found to be noninferior to VKAs for the primary composite endpoint of adverse clinical events. The rate of this endpoint was 17.5% per year in the edoxaban group and 16.5% per year in the VKA group (hazard ratio [HR] 1.05; 95% confidence interval [CI] 0.85–1.31; p=0.01 for noninferiority).

Regarding safety, the edoxaban group had a higher risk of major bleeding compared to the VKA group, mainly due to gastrointestinal bleeding. The rate of major bleeding was 9.7% per year in the edoxaban group and 7% per year in the VKA group (HR 1.40; 95% CI 1.03–1.91). In secondary analyses, patients in the edoxaban group who required a downward dose adjustment and those not prescribed oral antiplatelet therapy had a similar rate of major bleeding compared to the VKA group.

“ENVISAGE-TAVI AF suggests that treatment with edoxaban can be valuable in the management of this high-risk population of patients with atrial fibrillation after TAVI,” concludes Dangas.


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