Apixaban in Chronic Mechanical Circulatory Support in Patients Non-Compliant to Vitamin-K Based Anticoagulation

Abstract

Non-Compliance has been defined as an independent late risk factor for patients with chronic Mechanic Circulatory Support. Times in therapeutic range (TTR) above 70% in Vitamin K based anticoagulation (VKA) are only achieved with INR self-management and additional telephone surveillance requiring tremendous logistics and compliance.We investigated an alternative anticoagulation regime with Apixaban and Multiplate controlled platelet inhibition therapy in this sensitive cohort. Since July 2014, 48 patients with a mean age 65,6 years (36 to 82), supported by Medtronic HVAD (47) or Abbott Heartmate 3 (1), identified as non-compliant to VKA were anticoagulated by Apixaban 5mg bid and either Aspirin or Clopidogrel. Non-compliance was defined as either an inability to become trained to perform INR self-management or 3 INR values requiring intervention.Cerebrovascular events were assessed. Mean anticoagulation with Apixaban was 371 days (24 - 810), sum 17815 days. 33 patients received Clopidogrel, 14 Aspirin. Overall, 5 cerebrovascular events (10,5%) were documented. Of these, 2 were fatal hemorrhagic (4,1%) and 3 were ischemic events (6,3%), all resolving to a Modified Rankin Score of <3. One-year freedom of cerebrovascular, ischemic or hemorrhagic cerebrovascular events were 90%, 96% and 94%, respectively. Apixaban 5 mg bid and Multiplate-controlled platelet inhibition appears to be a safe and effective alternative in patients non-compliant to standard VKA in a single center observation. Larger trials to investigate Apixaban's potential to replace VKA as standard of care are needed.