In patients with atrial fibrillation and valvular heart disease, treatment with apixaban was associated with a lower risk of stroke or systemic embolism and bleeding compared with rivaroxaban, according to findings from a population-based study published in the Annals of Internal Medicine.

Apixaban and rivaroxaban are both factor Xa inhibitors approved by the Food and Drug Administration to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. To compare the efficacy and safety of these agents in patients with atrial fibrillation and concurrent valvular heart disease, researchers from the Perelman School of Medicine at the University of Pennsylvania used data from a large health insurance database to conduct a new-user, retrospective, active-comparator study.

The analysis included a total of 19,894 patients; 9947 in the apixaban group and 9947 in the rivaroxaban group. Each patient in the apixaban group was matched with one in the rivaroxaban group based on similar characteristics.

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Results showed that patients treated with apixaban had a 43% lower risk of ischemic stroke or systemic embolism compared with those who received rivaroxaban (hazard ratio [HR], 0.57; 95% CI, 0.40-0.80). For apixaban users, the rate of ischemic stroke or systemic embolism per patient per year of follow-up was calculated to be 0.52%; for rivaroxaban users, it was 0.91%.

Apixaban was also associated with a 49% lower risk of gastrointestinal or intracranial bleeding vs rivaroxaban (HR, 0.51; 95% CI, 0.41-0.62). No statistically significant difference was observed in all-cause mortality between the groups (HR, 1.10; 95% CI, 0.97-1.24).

“Until evidence from randomized controlled trials becomes available, we believe clinicians should consider our findings when selecting anticoagulants in patients with AF and VHD,” said study senior author Sean Hennessy, PharmD, PhD, a professor of Epidemiology and director of Penn’s Center for Real-world Effectiveness and Safety of Therapeutics.


  1. Dawwas GK, CukerA, Barnes GD, et al. Apixaban versus rivaroxaban in patients with atrial fibrillation and valvular heart disease: a population based study. Published online October 18, 2022. Annals of Internal Medicine.
  2. Stroke, clot risk halved in patients with heart disease and arrhythmia who took blood thinners apixaban versus rivaroxaban. News release. Accessed October 19, 2022.

This article originally appeared on MPR