Percutaneous Coronary Intervention and Antiplatelet Therapy on Apixaban or Warfarin: Insights From the ARISTOTLE Trial

Background: Few data exist about the combination of dual antiplatelet therapy (DAPT) and direct oral anticoagulants. Patients on DAPT were excluded from ARISTOTLE, but those who underwent percutaneous coronary intervention (PCI) during follow-up were allowed to continue study drug in addition to antiplatelet therapy. Methods: All patients in the intention-to-treat group of ARISTOTLE were included. Groups were divided based on performance of PCI during follow-up. Baseline clinical characteristics, PCI frequency, rates of concomitant antiplatelet therapy use, and post-PCI outcomes including stroke/SE and bleeding were reported. Results: Of 18,201 patients, 318 (1.7%) underwent PCI (apixaban group [n=153], warfarin group [n=165]) during the trial. Those who underwent PCI were more likely to have valvular heart disease, a history of TIA, and a higher CHADS 2 score but had similar rates of diabetes, prior MI, and CHF. Patients were on study drug at the time of PCI 78.3% of the time (n=249). Of these, 42 (16.8%) did not stop study drug, 78 (31.3%) stopped study drug at time of PCI and restarted u003e5 days after PCI, and 129 (51.8%) stopped and restarted 30 days) was used in 34.9% of patients, aspirin without P2Y12 was used in 23.1%, P2Y12 therapy without aspirin was used in 12.8%, and 29.2% reported using neither. In the post-PCI subgroup, apixaban-assigned patients had numerically similar rates of ISTH major bleeding (5.93 vs 5.82 events/100 pt-yrs) and stroke (2.74 vs 2.49 events/100 pt-yrs) compared with warfarin-assigned patients. Conclusions: In patients in ARISTOTLE, PCI occurred infrequently during follow-up. A majority of patients were on study drug at time of PCI and 17% of patients never stopped drug despite PCI. DAPT was used only one-third of the time. Bleeding and stroke rates were numerically similar between apixaban and warfarin groups in the post-PCI subgroup. Additional data are needed to guide apixaban use in patients undergoing PCI.