Patients with atrial fibrillation (Afib) and stable coronary artery disease (CAD) often face complex treatment decisions regarding antithrombotic therapy. A recent study, the EPIC-CAD trial, compared the efficacy of edoxaban monotherapy to dual antithrombotic therapy in this patient population. The findings of this trial, presented at the European Society of Cardiology (ESC) meeting and simultaneously published in the New England Journal of Medicine, shed light on the optimal approach to managing these high-risk patients.
According to the EPIC-CAD trial, patients on edoxaban monotherapy experienced a significant improvement in net outcomes compared to those on dual antithrombotic therapy. The composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, or major bleeding occurred less frequently in the edoxaban group (6.8%) than in the dual therapy group (16.2%). This difference was primarily driven by a lower incidence of bleeding, rather than major ischemic events. Major bleeding or clinically relevant nonmajor bleeding also occurred less frequently in the edoxaban monotherapy group (4.7%) compared to the dual therapy group (14.2%). These results suggest that edoxaban monotherapy may offer a more favorable risk-benefit profile for these patients.
The findings of the EPIC-CAD trial have important implications for clinical practice. They support existing guidelines from the ESC and American Heart Association/American College of Cardiology, which recommend oral anticoagulation alone 6-12 months after percutaneous coronary intervention (PCI) or acute coronary syndrome. The trial adds to a growing body of evidence favoring single antithrombotic therapy over dual therapy in patients with CAD. Clinicians should consider the bleeding benefits of monotherapy when selecting antithrombotic regimens for these patients.
Despite the clear benefits of edoxaban monotherapy demonstrated in the EPIC-CAD trial, there are still challenges in clinical practice. The timing of transitioning to a single agent after the early post-event period remains unclear. Evidence suggests that many patients do not discontinue dual antithrombotic therapy when indicated, highlighting the need for improved adherence to guidelines. Clinicians must carefully weigh the risks and benefits of antithrombotic therapy in individual patients to optimize outcomes.
It is important to acknowledge the limitations of the EPIC-CAD trial. The study was underpowered for thrombotic events as a sole endpoint, which may have impacted the interpretation of the primary outcomes. Additionally, the trial included a predominantly Asian patient population, which may limit the generalizability of the findings to other ethnicities. Further research is needed to confirm the efficacy and safety of edoxaban monotherapy in more diverse patient populations.
The EPIC-CAD trial provides valuable insights into the management of patients with Afib and stable CAD. Edoxaban monotherapy appears to offer superior outcomes in terms of bleeding risk and net clinical benefit compared to dual antithrombotic therapy. Clinicians should consider these findings when making treatment decisions for this high-risk patient population. Further research is needed to clarify the optimal timing and duration of antithrombotic therapy in these patients and to address the limitations of the current study.
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