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The direct oral anticoagulant apixaban was recently found noninferior in efficacy and superior in preventing major bleeding compared with LMWH/VKAs in the AMPLIFY (Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-Line Therapy) trial.
Apixaban consistently reduced the rate of stroke and systemic embolism, death, and major bleeding compared with warfarin in amiodarone-treated patients and patients who were not on amiodarone.
A meta-analysis of published phase II and III studies found that, overall, the non-VKA OACs had equivalent efficacy in terms of preventing VTE recurrence compared with VKAs, but rivaroxaban was the only agent to significantly reduce the risk of major bleeding compared with standard care [22].
Apixaban was associated with similar efficacy but less major bleeding compared with rivaroxaban.
Stroke and systemic emboli rates are increased as is major bleeding compared with patients <75 years.
However, standard adjusted dose VKA was associated with an increased risk of major bleeding compared with placebo or observation.
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In the phase II Dose confIrmation Study assessing anti-Platelet Effects of AZD6140 vs clopidogRel in non ST-segment Elevationon ST-segmentnfarction-2 (DISPElevationrial of 990 patients with NSTEmyocardialcagrelor treatment with 90 mg and 180 mg twice daily showed comparable rates of major and minor bleeding compared witrialofidogrel (75 mg), with numerically fewer MIs.
In the phase II DISPERSE-2 trial of 990 patients with non-ST-elevation acute coronary syndromes (ACS), ticagrelor treatment with 90 mg and 180 mg twice daily showed comparable rates of major and minor bleeding compared with clopidogrel 75 mg while there were numerically fewer myocardial infarctions.
Rivaroxaban and DE showed an increased risk of major gastrointestinal bleeding compared with warfarin.
This study found edoxaban 30, 45 and 60 mg once daily were associated with comparable rates of all bleeding, major bleeding, and major and CRNM bleeding compared with warfarin, and there were no statistically significant differences between groups.
In the double blind ROCKET-AF trial patients on rivaroxaban 20 mg od had reduced rates of stroke and systemic embolism and comparable major bleeding incidences compared to warfarin [ 3].
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