In a multicentre randomised trial, edoxaban monotherapy reduced nonfatal major and clinically relevant nonmajor bleeding without excess risk for ischaemic events.

In most patients with atrial fibrillation (AF) and a recent percutaneous coronary intervention or acute coronary syndrome, dual therapy with an anticoagulant plus a single antiplatelet drug reduces the risk for bleeding events without a major increase in ischaemic events (NEJM JW Cardiol Mar 17 2019 and N Engl J Med 2019; 380: 1509-1524; and NEJM JW Cardiol Sep 3 2019 and Lancet 2019; 394: 1335-1343). Nevertheless, the optimal regimen for patients with AF and stable coronary artery disease (CAD) remains unclear. In the industry-funded, multicentre, open-label, randomised EPIC- CAD trial from South Korea, researchers compared edoxaban monotherapy with anticoagulation plus clinician-selected antiplatelet monotherapy in 1040 patients with AF and stable CAD (NCT03718559).

At 12 months, Kaplan-Meier incidence of the primary composite outcome – all-cause death, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularisation and major or clinically relevant nonmajor bleeding – was significantly lower in the edoxaban group than the dual-therapy group (7% vs 16%; hazard ratio, 0.44), driven primarily by a reduction in nonfatal, non-intracranial major and nonmajor bleeding events (HR, 0.34).

Neither death nor ischaemic events differed significantly between the two groups. 

Comment: The findings from EPIC-CAD align well with those from the previously published AFIRE trial (NEJM JW Cardiol Sep 2 2019 and N Engl J Med 2019; 381: 1103-1113), as also reported in the accompanying editorial. Given the available data, for the majority of patients with AF and stable CAD who require anticoagulation, I consider anticoagulant monotherapy. Dual therapy to reduce ischaemic risk may still be warranted in a minority of patients, but EPIC-CAD has reinforced that those patients are the exception, not the norm.

Behnood Bikdeli, MD, MS, Associate Physician, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston; Instructor in Medicine, Harvard Medical School, Boston; Investigator, Yale New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, USA.

Cho MS, et al. Edoxaban antithrombotic ther­apy for atrial fibrillation and stable coronary artery disease. N Engl J Med 2024 Sep 1; e­pub (https://doi.org/10.1056/NEJMoa2407362). Lip GYH. Atrial fibrillation and stable coronary artery disease. N Engl J Med 2024 Sep 1; e­pub (www.nejm.org/doi/full/10.1056/ NEJMe2409696).

This summary is taken from the following Journal Watch titles: Cardiology, General Medicine, Ambulatory Medicine.