Echocardiographic Risk Factors for Stroke and Outcomes in Patients With Atrial Fibrillation Anticoagulated With Apixaban or Warfarin.

Abstract

BACKGROUND AND PURPOSE:

Few data exist on the long-term outcomes of patients with spontaneous echo contrast (SEC), left atrial/left atrial appendage (LA/LAA) thrombus, and complex aortic plaque (CAP), in patients with atrial fibrillation receiving oral anticoagulation. We explored the relationship between these 3 echocardiographic findings and clinical outcomes, and the comparative efficacy and safety of apixaban and warfarin for each finding.

METHODS:

Patients from the ARISTOTLE trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) with SEC, LA/LAA thrombus, or CAP diagnosed by either transthoracic or transesophageal echocardiography were compared with patients with none of these findings on transesophageal echocardiography.

RESULTS:

A total of 1251 patients were included: 217 had SEC, 127 had LA/LAA thrombus, 241 had CAP, and 746 had none. The rates of stroke/systemic embolism were not significantly different among patients with and without these echocardiographic findings (hazard ratio, 0.96; 95% confidence interval, 0.25-3.60 for SEC; hazard ratio, 1.27; 95% confidence interval, 0.23-6.86 for LA/LAA thrombus; hazard ratio, 2.21; 95% confidence interval, 0.71-6.85 for CAP). Rates of ischemic stroke, myocardial infarction, cardiovascular death, and all-cause death were also not different between patients with and without these findings. For patients with either SEC or CAP, there was no evidence of a differential effect of apixaban over warfarin. For patients with LA/LAA thrombus, there was also no significant interaction, with the exception of all-cause death and any bleeding where there was a greater benefit of apixaban compared with warfarin among patients with no LA/LAA thrombus.

CONCLUSIONS:

In anticoagulated patients with atrial fibrillation and risk factors for stroke, echocardiographic findings do not seem to add to the risk of thromboembolic events.

CLINICAL TRIAL REGISTRATION:

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412984.

• Authors: Dragos Vinereanu, Renato D Lopes, Hillary Mulder, Bernard J Gersh, Michael Hanna, Pedro G M de Barros E Silva, Dan Atar, Lars Wallentin, Christopher B Granger, John H Alexander, ARISTOTLE Investigators
• Journal: Stroke (Stroke) Vol. 48 Issue 12 Pg. 3266-3273 (12 2017) ISSN: 1524-4628 [Electronic] United States
• PMID: 29089455 (Publication Type: Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)
• Copyright: © 2017 American Heart Association, Inc.

Chemical References

• Anticoagulants
• Pyrazoles
• Pyridones
• apixaban
• Warfarin

Topics

• Aged
• Anticoagulants (adverse effects, therapeutic use)
• Atrial Fibrillation (complications, drug therapy, mortality)
• Brain Ischemia (epidemiology, mortality)
• Cardiovascular Diseases (epidemiology, mortality)
• Double-Blind Method
• Echocardiography
• Electrocardiography
• Female
• Humans
• Male
• Middle Aged
• Myocardial Infarction (complications, mortality)
• Plaque, Atherosclerotic (epidemiology, mortality)
• Pyrazoles (adverse effects, therapeutic use)
• Pyridones (adverse effects, therapeutic use)
• Risk Factors
• Stroke (epidemiology, etiology, mortality)
• Thromboembolism (epidemiology)
• Treatment Outcome
• Warfarin (adverse effects, therapeutic use)