Post-TAVR bleeding in AFib patients much less common with apixaban than rivaroxaban
Apixaban is associated with a much lower risk of major bleeding events after transcatheter aortic valve replacement (TAVR) than rivaroxaban, according to a new retrospective study published in The American Journal of Cardiology.[1]
Researchers explored data from more than 4,000 TAVR patients who underwent treatment from 2010 to 2024. Patients were discharged on one of the two popular direct oral anticoagulants (DOACs)—apixaban or rivaroxaban—for atrial fibrillation (AFib). Any patients who alternated from one DOAC to the other or received warfarin at discharge were excluded from the analysis.
All data came from the TriNetX research platform.
The study's authors turned to propensity-score matching to focus on two comparable groups of 2,157 patients—one that received apixaban and another that received rivaroxaban. Overall, after a median follow-up period of nearly two years, apixaban was associated with 592 major bleeding events and rivaroxaban was associated with 486 major bleeding events. For other key outcomes—including intracranial hemorrhage, all-cause mortality, ischemic stroke, thromboembolism, AFib-related encounters and cardiovascular hospitalization—there were no significant differences.
“Several pharmacologic factors may underlie the divergent bleeding risks,” wrote first author Olivier Morel, MD, PhD, a professor of cardiovascular medicine at the University of Strasbourg in France, and colleagues. “Rivaroxaban’s once-daily dosing produces higher peak anticoagulant levels, whereas apixaban’s twice-daily regimen yields more consistent plasma concentrations. Rivaroxaban also demonstrates greater bioavailability and extended luminal exposure contact time within the gastrointestinal tract, which may contribute to mucosal injury. Variability in factor Xa inhibition kinetics, renal elimination, or patient selection may further modulate risk.”
The group also highlighted the “substantial clinical and economic burden” associated with post-TAVR bleeding events.
“In this high-risk setting, where advanced age, frailty and comorbidity burden amplify bleeding susceptibility, our findings provide clinically relevant, procedure-specific data,” the authors wrote. “Given the 14% relative reduction in major bleeding observed with apixaban, averting 100 major bleeding events per 10,000 treated patients could translate into $1–4.5 million in avoided direct medical expenditures. These estimates do not capture downstream societal burdens including functional decline, caregiver needs or long-term and reduced independence, which further magnify the overall impact.”
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Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.