Adding DOACs Beneficial for STEMI — Not Non-STEMI — But with Bleeding Risk

By Amy Orciari Herman

Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, DFASAM

For patients with acute coronary syndrome, adding a direct-acting oral anticoagulant (DOAC) to antiplatelet therapy seems beneficial only for those with ST-segment elevation myocardial infarction (STEMI), finds a JAMA Cardiology meta-analysis.

Six placebo-controlled trials examined the effects of adding a DOAC (apixaban, rivaroxaban, or dabigatran) to antiplatelet therapy in 30,000 patients with STEMI or non-STEMI.

Among STEMI patients, adding a DOAC was associated with significantly reduced risk for major cardiovascular events — but with significantly increased risk for major bleeding. However, the researchers say the risk-benefit profile was favorable: 63 STEMI patients would need to receive a DOAC to prevent one cardiovascular event, while 96 would need to be treated to cause one major bleeding event.

Meanwhile, in non-STEMI patients, DOAC therapy did not significantly lower cardiovascular risk, and the increased bleeding risk persisted — yielding an unfavorable risk-benefit profile. Specifically, 130 non-STEMI patients would need to be treated to prevent one cardiovascular event, while 137 would need to be treated to cause one major bleed.

Dr. Harlan Krumholz of NEJM Journal Watch Cardiology commented: "The most important thing for treatments with trade-offs is to ensure patients understand well how the benefits compare with the risks. Where evidence for benefit is absent, then there is little to discuss; but even for patients who, on average, may benefit, the risks that they incur are still important to discuss. Ultimately, people may weigh these benefits and risks differently."