Edoxaban plus aspirin de-escalation strategy versus continuous dual antithrombotic therapy in the perioperative period for patients with atrial fibrillation undergoing carotid artery stenting: a retrospective cohort study.

Abstract

Objective: To compare the safety and efficacy of an edoxaban-based, time-limited dual antithrombotic therapy followed by a de-escalation strategy versus a continuous dual antithrombotic strategy in patients with atrial fibrillation (AF) undergoing carotid artery stenting (CAS).

Methods: A total of 120 patients with CAS and AF who underwent surgery at Guizhou Panjiang Investment Holding (Group) Co., Ltd. General Hospital from June 2023 to December 2024 were retrospectively enrolled. According to the perioperative antithrombotic regimen, patients were divided into a de-escalation group (n=56) and a dual therapy group (n=64). Patients in the de-escalation group received edoxaban (standard dose) combined with aspirin (100 mg/d) preoperatively and during the first 6 months postoperatively, after which aspirin was discontinued and edoxaban monotherapy was continued from 6 to 12 months postoperatively. Patients in the dual therapy group received continuous treatment with edoxaban plus aspirin throughout the 12-month follow-up period. Platelet count, C-reactive protein (CRP), D-dimer, fibrinogen, and coagulation parameters, including prothrombin time (PT), thrombin time (TT), and activated partial thromboplastin time (APTT), were compared at 1, 6, and 12 months postoperatively. Bleeding events, embolic events, adverse reactions, carotid artery restenosis, stent thrombosis, health-related quality of life (EQ-5D-5L), and treatment adherence were recorded.

Results: Baseline characteristics were comparable between the two groups. After treatment, platelet count, CRP, D-dimer, and fibrinogen levels significantly decreased, whereas PT, TT, and APTT were significantly prolonged in both groups, with no significant intergroup differences. There was no significant difference in the incidence of vascular restenosis or stent thrombosis between the two groups (P>0.05). At 12 months postoperatively, the de-escalation group had a significantly lower incidence of bleeding events than the dual therapy group (8.93% vs. 23.44%, P=0.033), whereas the incidence of embolic events was comparable between groups (14.29% vs. 9.38%, P=0.403). The incidence of bleeding events during the 6-12-month postoperative period was significantly lower in the de-escalation group. Subgroup analyses stratified by CHA₂DS₂-VASc score and HAS-BLED score showed consistently lower bleeding rates in the de-escalation group, with no significant increase in embolism events. At 12 months, the de-escalation group showed significantly higher EQ-5D utility index and VAS scores, higher overall medication adherence (87.50% vs. 73.43%, P=0.035), and a lower rate of permanent treatment discontinuation due to adverse reactions (3.57% vs. 14.06%, P=0.047).

Conclusion: In patients with AF undergoing CAS, an edoxaban-based de-escalation strategy involving conversion to monotherapy at 6 months postoperatively was non-inferior to continuous dual antithrombotic therapy in preventing ischemic events. This strategy significantly reduced bleeding risk at 12 months postoperatively and improved quality of life and treatment adherence, representing a safe and effective perioperative antithrombotic management regimen.