Secondary analysis from the AUGUSTUS trial (first published in 2019) presented at the American Stroke Association’s International Stroke Conference 2020, showed that treatment with apixaban without aspirin resulted in less bleeding and fewer deaths and hospitalisations than warfarin.
The AUGUSTUS trial compared patients (N=4,614) with atrial fibrillation and acute coronary syndrome or undergoing percutaneous coronary intervention with a planned P2Y12 inhibitor antiplatelet drug, randomly assigned to apixaban or vitamin K agonist with aspirin or placebo for six months. In a secondary analysis of 4,581 patients, 13.8 per cent had prior stroke, transient ischaemic attack or thromboembolism.
Analysis showed that patients with prior stroke were at increased risk of ischaemic stroke, bleeding, hospitalisation or death compared with those with no prior stroke. Furthermore, the use of apixaban without aspirin was associated with the lowest rate of bleeding, death or hospitalisation, regardless of history of prior stroke. The highest rate of bleeding was seen in patients who received the combination of a vitamin K antagonist plus aspirin. The risk of bleeding was higher with aspirin than placebo among patients with no prior events and there was no significant difference between aspirin and placebo observed between patients with and without prior stroke for other clinical outcomes.
Thus, apixaban plus a P2Y12 inhibitor without aspirin had the most favourable outcomes.