Evidence guiding antithrombotic strategy in patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention with drug-eluting stents (DES) is evolving. Older patients present a particular challenge because they have elevated risks of both ischemic events and bleeding. The ADAPT AF-DES randomised trial compared NOAC monotherapy with combination therapy of NOAC plus clopidogrel; this report presents a post hoc analysis stratified by age to assess safety and efficacy differences in older versus younger patients.
This analysis is a secondary, post hoc evaluation of the ADAPT AF-DES randomised trial. The trial randomized patients with AF who received drug-eluting stents to either NOAC monotherapy or NOAC plus clopidogrel. The NOAC agents used in the study were apixaban or rivaroxaban. Patients were stratified for analysis by age: those aged ≥75 years and those aged <75 years.
Across the trial, 960 patients were included; 376 (39.2%) were aged 75 years or older. The primary analysis assessed outcomes at 1 year after randomisation. The source abstract does not report some operational details such as exact NOAC dosing regimens, timing of randomisation relative to stenting, or any run-in antiplatelet duration prior to monotherapy.
The primary endpoint for this analysis was a composite net adverse clinical event at 1 year, defined as any of the following: all-cause death, myocardial infarction, stent thrombosis, stroke, systemic embolism, or major or clinically relevant non-major bleeding classified by the International Society on Thrombosis and Haemostasis (ISTH) criteria.
In the subgroup of patients aged ≥75 years, the incidence of the primary composite endpoint at 1 year was lower in the NOAC monotherapy group compared with the combination therapy group (9.8% vs. 22.3%). The adjusted hazard ratio for NOAC monotherapy versus combination therapy in this age group was 0.37 (95% confidence interval 0.21–0.66; P < .001).
For patients aged <75 years, the incidence of the primary endpoint did not differ significantly between NOAC monotherapy and NOAC plus clopidogrel. When formally testing interaction between age category and assigned treatment strategy for the primary endpoint, the P value for interaction was 0.095, which did not meet conventional thresholds for statistical significance.
The analysis reported a consistent reduction in major or clinically relevant non-major bleeding with NOAC monotherapy across both age groups. The abstract indicates that the bleeding benefit of NOAC monotherapy did not vary meaningfully between patients aged ≥75 years and those <75 years.
Although bleeding reductions were consistent across ages, the benefit of NOAC monotherapy on major adverse cardiac and cerebrovascular events (a component of ischemic outcomes within the composite) was more pronounced in the older subgroup (≥75 years). The authors report a statistically significant interaction for this ischemic outcome, indicating a greater relative reduction in these events with NOAC monotherapy among older patients compared with younger patients.
In this post hoc age-stratified analysis of ADAPT AF-DES, NOAC monotherapy after drug-eluting stent implantation was associated with a lower risk of the 1-year net adverse clinical event composite in patients aged ≥75 years compared with NOAC plus clopidogrel. The data suggest that older patients derive particular net clinical benefit from simplifying antithrombotic therapy to NOAC alone, driven by both reductions in bleeding and a pronounced reduction in major adverse cardiac and cerebrovascular events in the older subgroup.
Given these findings, clinicians may consider age and individual ischemic versus bleeding risk when selecting an antithrombotic regimen after stenting in patients with AF. The authors highlight the potential need for a tailored approach rather than a one-size-fits-all strategy.
This report is a post hoc secondary analysis and thus hypothesis-generating rather than definitive. The source abstract does not provide several trial details that might influence interpretation, including exact NOAC doses, the proportion of patients on apixaban versus rivaroxaban, timing of antithrombotic strategy initiation relative to PCI, duration of any early combination therapy, detailed subgroup event counts beyond those summarized, and the full list of covariates used in the adjusted hazard models. The interaction for the primary composite did not reach statistical significance (P for interaction = 0.095), which should temper strong causal inference about age-specific effects. Readers should consult the full trial report for complete methods and results before changing practice.
The ADAPT AF-DES post hoc analysis reports that NOAC monotherapy was associated with a lower 1-year net adverse clinical event rate in patients aged ≥75 years with AF who received drug-eluting stents, while no significant difference was seen in younger patients. The bleeding benefit of NOAC monotherapy was consistent across ages, and ischemic outcome benefits appeared greater in older patients. The authors recommend individualized antithrombotic decisions that account for age and ischemic risk. Full trial details and confirmatory studies are needed to guide definitive practice changes.