New late-breaking science from AHA 2023 sheds light on new treatments for patients with atrial fibrillation (AFib).

In ARTESIA, the results of which were also published in the New England Journal of Medicine, patients with subclinical AFib who were treated with apixaban (5 mg/twice daily) were 37% less likely to have a stroke or systemic embolism compared with patients taking aspirin (81 mg/daily). This finding was primarily driven by a 51% reduction in fatal or disabling stroke, researchers said. However, patients in the apixaban group had a 74% higher chance of major bleeding.

“Currently, there is no consistent guidance on how to treat subclinical AFib in people with implanted heart devices,” said Jeff Healey, MD, MS. “I think the results of ARTESIA are strong enough to change the way we practice and lead to changes in management guidelines so that we recommend that many of these individuals who have subclinical AFib receive an anticoagulant. The study’s findings will also help to address ongoing questions about the potential value of population-based screening for AFib.”

In a related editorial, Emma Svennberg, MD, PhD, writes: “Apixaban treatment in patients with subclinical AFib prevented severe strokes at the price of an increased risk of nonfatal bleed­ing. Going forward, we must balance the in­creased bleeding risks with the risk for disabling strokes. In patients with subclinical AFib, vital components of care management include shared decision-making before oral anti­coagulant treatment, management of modifiable bleeding risks and coexisting conditions, and close monitoring of progression to clinical AFib.”

In a second trial, researchers found that dual cardioversion for AFib was more effective than conventional single cardioversion in obese patients (BMI ≥35 kg/m2), without an increased risk of complications or discomfort. In presenting the findings, Joshua D. Aymond, MD, also noted that no procedure-related adverse outcomes were observed.

Findings from AZALEA-TIMI 71 showed bleeding was reduced by more than 60% with abelacimab (90 mg or 150 mg via monthly injection) vs. rivaroxaban (20 mg) in patients with AFib who were at moderate to high risk of stroke. The trial was stopped early in September 2023 due to an “overwhelming reduction” in bleeding with the novel factor XI/XIa inhibitor.

“This trial confirms the promise of abelacimab to be an incredibly safe anticoagulant for stroke prevention in people with AFib,” said study author Christian T. Ruff, MD, MPH, who also noted the trial is the longest and largest trial to-date comparing factor XI inhibitors to direct-acting oral anticoagulants.

Lastly, in a prespecified subanalysis of the NOAH-AFNET 6 trial, the rate of stroke appeared low in patients with atrial high-rate episodes (AHRE) ≥24 hours who were treated with edoxaban compared with no anticoagulation. Researchers noted no interaction between the duration of the longest AHRE episode and the efficacy and safety of oral anticoagulation. Additionally, patients experiencing AHRE durations ≥24 hours were more likely to develop AFib over time than those with shorter AHRE, underscoring the need for regular ECGs, researchers said.