Atrial fibrillation (Afib) and stable coronary artery disease (CAD) are common conditions that often require antithrombotic therapy. A recent trial, EPIC-CAD, evaluated the use of edoxaban (Savaysa) monotherapy in these patients and compared it with dual antithrombotic therapy. The results of the trial revealed significant improvements in net outcomes, particularly in terms of bleeding and ischemic events.
The 12-month composite endpoint, which included death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, and major bleeding or clinically relevant nonmajor bleeding, was significantly lower in the edoxaban monotherapy group compared to the dual antithrombotic therapy group. The difference was primarily driven by a reduction in bleeding events, while there was no significant disparity in major ischemic events between the two groups.
The results of the EPIC-CAD trial align with current guidelines from the European Society of Cardiology (ESC) and the American Heart Association/American College of Cardiology, which recommend oral anticoagulation alone for patients with CAD after percutaneous coronary intervention (PCI) or acute coronary syndrome. The evidence presented in the trial suggests that single antithrombotic therapy may be more favorable than dual therapy in this patient population.
While the findings of the EPIC-CAD trial are promising, some challenges remain in clinical practice. The timing of transitioning to a single antithrombotic agent after an acute event is still unclear, and many patients may continue dual therapy despite recommendations to discontinue it. Clinicians should carefully evaluate the clinical justification for dual therapy in each patient and consider the potential benefits of a single-agent regimen.
It is important to note that the EPIC-CAD trial was underpowered for thrombotic events as a sole endpoint, which may limit the generalizability of the findings. Additionally, the study included a predominantly Asian population, and while the results may differ in non-Asian patients, previous research has not shown significant differences in the effectiveness of antithrombotic therapy between the two groups.
The EPIC-CAD trial demonstrated that edoxaban monotherapy may be a preferable treatment option for patients with Afib and stable CAD compared to dual antithrombotic therapy. By focusing on net outcomes and considering the balance between bleeding and ischemic events, clinicians can make more informed decisions regarding antithrombotic therapy in this patient population. Further research is needed to fully understand the optimal timing and duration of antithrombotic therapy in these patients.
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