Efficacy and safety of apixaban vs warfarin in patients with atrial fibrillation and prior bioprosthetic valve replacement or valve repair: Insights from the ARISTOTLE trial

Background The optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair remains uncertain. Hypothesis We evaluated the safety and efficacy of apixaban vs warfarin in patients with AF and a history of BPV replacement...

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Published in:Clinical cardiology (Mahwah, N.J.) Vol. 42; no. 5; pp. 568 - 571
Main Authors: Guimarães, Patricia O., Pokorney, Sean D., Lopes, Renato D., Wojdyla, Daniel M., Gersh, Bernard J., Giczewska, Anna, Carnicelli, Anthony, Lewis, Basil S., Hanna, Michael, Wallentin, Lars, Vinereanu, Dragos, Alexander, John H., Granger, Christopher B.
Format: Journal Article
Language:English
Published: New York Wiley Periodicals, Inc 01.05.2019
John Wiley & Sons, Inc
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ISSN:0160-9289, 1932-8737, 1932-8737
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Abstract Background The optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair remains uncertain. Hypothesis We evaluated the safety and efficacy of apixaban vs warfarin in patients with AF and a history of BPV replacement or native valve repair. Methods Using data from Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) (n = 18 201), a randomized trial comparing apixaban with warfarin in patients with AF, we analyzed the subgroup of patients (n = 251) with prior valve surgery. We contacted sites by telephone to obtain additional data about prior valve surgery. Full data were available for 156 patients. The primary efficacy endpoint was stroke/systemic embolism. The primary safety endpoint was major bleeding. Treatment groups were compared using a Cox regression model. Results In ARISTOTLE, 104 (0.6%) patients had a history of BPV replacement (n = 73 [aortic], n = 26 [mitral], n = 5 [mitral and aortic]) and 52 (0.3%) had a history of valve repair (n = 50 [mitral], n = 2 [aortic]). Among patients with BPVs, 55 were randomized to apixaban and 49 to warfarin. Among those with a history of native valve repair, 32 were randomized to apixaban and 20 to warfarin. Overall clinical event rates were low, with no significant differences between apixaban and warfarin for any outcomes. Conclusions In patients with AF and a history of BPV replacement or repair, the safety and efficacy of apixaban compared with warfarin was consistent with results from ARISTOTLE. These data suggest that apixaban may be reasonable for patients with BPVs or prior valve repair, though future larger randomized trials are needed. ClinicalTrials.gov NCT00412984.
AbstractList Background The optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair remains uncertain. Hypothesis We evaluated the safety and efficacy of apixaban vs warfarin in patients with AF and a history of BPV replacement or native valve repair. Methods Using data from Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) (n = 18 201), a randomized trial comparing apixaban with warfarin in patients with AF, we analyzed the subgroup of patients (n = 251) with prior valve surgery. We contacted sites by telephone to obtain additional data about prior valve surgery. Full data were available for 156 patients. The primary efficacy endpoint was stroke/systemic embolism. The primary safety endpoint was major bleeding. Treatment groups were compared using a Cox regression model. Results In ARISTOTLE, 104 (0.6%) patients had a history of BPV replacement (n = 73 [aortic], n = 26 [mitral], n = 5 [mitral and aortic]) and 52 (0.3%) had a history of valve repair (n = 50 [mitral], n = 2 [aortic]). Among patients with BPVs, 55 were randomized to apixaban and 49 to warfarin. Among those with a history of native valve repair, 32 were randomized to apixaban and 20 to warfarin. Overall clinical event rates were low, with no significant differences between apixaban and warfarin for any outcomes. Conclusions In patients with AF and a history of BPV replacement or repair, the safety and efficacy of apixaban compared with warfarin was consistent with results from ARISTOTLE. These data suggest that apixaban may be reasonable for patients with BPVs or prior valve repair, though future larger randomized trials are needed. ClinicalTrials.gov NCT00412984.
The optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair remains uncertain.BACKGROUNDThe optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair remains uncertain.We evaluated the safety and efficacy of apixaban vs warfarin in patients with AF and a history of BPV replacement or native valve repair.HYPOTHESISWe evaluated the safety and efficacy of apixaban vs warfarin in patients with AF and a history of BPV replacement or native valve repair.Using data from Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) (n = 18 201), a randomized trial comparing apixaban with warfarin in patients with AF, we analyzed the subgroup of patients (n = 251) with prior valve surgery. We contacted sites by telephone to obtain additional data about prior valve surgery. Full data were available for 156 patients. The primary efficacy endpoint was stroke/systemic embolism. The primary safety endpoint was major bleeding. Treatment groups were compared using a Cox regression model.METHODSUsing data from Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) (n = 18 201), a randomized trial comparing apixaban with warfarin in patients with AF, we analyzed the subgroup of patients (n = 251) with prior valve surgery. We contacted sites by telephone to obtain additional data about prior valve surgery. Full data were available for 156 patients. The primary efficacy endpoint was stroke/systemic embolism. The primary safety endpoint was major bleeding. Treatment groups were compared using a Cox regression model.In ARISTOTLE, 104 (0.6%) patients had a history of BPV replacement (n = 73 [aortic], n = 26 [mitral], n = 5 [mitral and aortic]) and 52 (0.3%) had a history of valve repair (n = 50 [mitral], n = 2 [aortic]). Among patients with BPVs, 55 were randomized to apixaban and 49 to warfarin. Among those with a history of native valve repair, 32 were randomized to apixaban and 20 to warfarin. Overall clinical event rates were low, with no significant differences between apixaban and warfarin for any outcomes.RESULTSIn ARISTOTLE, 104 (0.6%) patients had a history of BPV replacement (n = 73 [aortic], n = 26 [mitral], n = 5 [mitral and aortic]) and 52 (0.3%) had a history of valve repair (n = 50 [mitral], n = 2 [aortic]). Among patients with BPVs, 55 were randomized to apixaban and 49 to warfarin. Among those with a history of native valve repair, 32 were randomized to apixaban and 20 to warfarin. Overall clinical event rates were low, with no significant differences between apixaban and warfarin for any outcomes.In patients with AF and a history of BPV replacement or repair, the safety and efficacy of apixaban compared with warfarin was consistent with results from ARISTOTLE. These data suggest that apixaban may be reasonable for patients with BPVs or prior valve repair, though future larger randomized trials are needed. CLINICALTRIALS.GOV: NCT00412984.CONCLUSIONSIn patients with AF and a history of BPV replacement or repair, the safety and efficacy of apixaban compared with warfarin was consistent with results from ARISTOTLE. These data suggest that apixaban may be reasonable for patients with BPVs or prior valve repair, though future larger randomized trials are needed. CLINICALTRIALS.GOV: NCT00412984.
The optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair remains uncertain. We evaluated the safety and efficacy of apixaban vs warfarin in patients with AF and a history of BPV replacement or native valve repair. Using data from Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) (n = 18 201), a randomized trial comparing apixaban with warfarin in patients with AF, we analyzed the subgroup of patients (n = 251) with prior valve surgery. We contacted sites by telephone to obtain additional data about prior valve surgery. Full data were available for 156 patients. The primary efficacy endpoint was stroke/systemic embolism. The primary safety endpoint was major bleeding. Treatment groups were compared using a Cox regression model. In ARISTOTLE, 104 (0.6%) patients had a history of BPV replacement (n = 73 [aortic], n = 26 [mitral], n = 5 [mitral and aortic]) and 52 (0.3%) had a history of valve repair (n = 50 [mitral], n = 2 [aortic]). Among patients with BPVs, 55 were randomized to apixaban and 49 to warfarin. Among those with a history of native valve repair, 32 were randomized to apixaban and 20 to warfarin. Overall clinical event rates were low, with no significant differences between apixaban and warfarin for any outcomes. In patients with AF and a history of BPV replacement or repair, the safety and efficacy of apixaban compared with warfarin was consistent with results from ARISTOTLE. These data suggest that apixaban may be reasonable for patients with BPVs or prior valve repair, though future larger randomized trials are needed. CLINICALTRIALS.GOV: NCT00412984.
BackgroundThe optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair remains uncertain.HypothesisWe evaluated the safety and efficacy of apixaban vs warfarin in patients with AF and a history of BPV replacement or native valve repair.MethodsUsing data from Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) (n = 18 201), a randomized trial comparing apixaban with warfarin in patients with AF, we analyzed the subgroup of patients (n = 251) with prior valve surgery. We contacted sites by telephone to obtain additional data about prior valve surgery. Full data were available for 156 patients. The primary efficacy endpoint was stroke/systemic embolism. The primary safety endpoint was major bleeding. Treatment groups were compared using a Cox regression model.ResultsIn ARISTOTLE, 104 (0.6%) patients had a history of BPV replacement (n = 73 [aortic], n = 26 [mitral], n = 5 [mitral and aortic]) and 52 (0.3%) had a history of valve repair (n = 50 [mitral], n = 2 [aortic]). Among patients with BPVs, 55 were randomized to apixaban and 49 to warfarin. Among those with a history of native valve repair, 32 were randomized to apixaban and 20 to warfarin. Overall clinical event rates were low, with no significant differences between apixaban and warfarin for any outcomes.ConclusionsIn patients with AF and a history of BPV replacement or repair, the safety and efficacy of apixaban compared with warfarin was consistent with results from ARISTOTLE. These data suggest that apixaban may be reasonable for patients with BPVs or prior valve repair, though future larger randomized trials are needed.ClinicalTrials.govNCT00412984.
Author Pokorney, Sean D.
Giczewska, Anna
Hanna, Michael
Vinereanu, Dragos
Wojdyla, Daniel M.
Alexander, John H.
Granger, Christopher B.
Lewis, Basil S.
Wallentin, Lars
Carnicelli, Anthony
Lopes, Renato D.
Gersh, Bernard J.
Guimarães, Patricia O.
AuthorAffiliation 1 Duke Clinical Research Institute Duke University School of Medicine Durham North Carolina
3 Department of Biomedical Engineering, Faculty of Electronics Telecommunications and Informatics, Gdansk University of Technology Poland
7 Department of Cardiology University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital Bucharest Romania
5 Bristol‐Myers Squibb Princeton New Jersey
4 Department of Cardiovascular Medicine Lady Davis Carmel Medical Center Haifa Israel
2 Division of Cardiovascular Diseases Mayo Clinic College of Medicine Rochester Minnesota
6 Uppsala Clinical Research Center, Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
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– name: 6 Uppsala Clinical Research Center, Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
– name: 2 Division of Cardiovascular Diseases Mayo Clinic College of Medicine Rochester Minnesota
– name: 4 Department of Cardiovascular Medicine Lady Davis Carmel Medical Center Haifa Israel
– name: 1 Duke Clinical Research Institute Duke University School of Medicine Durham North Carolina
– name: 3 Department of Biomedical Engineering, Faculty of Electronics Telecommunications and Informatics, Gdansk University of Technology Poland
– name: 7 Department of Cardiology University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital Bucharest Romania
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  surname: Guimarães
  fullname: Guimarães, Patricia O.
  organization: Duke University School of Medicine
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  surname: Pokorney
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  organization: Duke University School of Medicine
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  fullname: Wojdyla, Daniel M.
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  organization: Mayo Clinic College of Medicine
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  organization: Duke University School of Medicine
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  givenname: Basil S.
  surname: Lewis
  fullname: Lewis, Basil S.
  organization: Lady Davis Carmel Medical Center
– sequence: 9
  givenname: Michael
  surname: Hanna
  fullname: Hanna, Michael
  organization: Bristol‐Myers Squibb
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  givenname: Lars
  surname: Wallentin
  fullname: Wallentin, Lars
  organization: Uppsala University
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  givenname: Dragos
  surname: Vinereanu
  fullname: Vinereanu, Dragos
  organization: University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital
– sequence: 12
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  surname: Alexander
  fullname: Alexander, John H.
  organization: Duke University School of Medicine
– sequence: 13
  givenname: Christopher B.
  surname: Granger
  fullname: Granger, Christopher B.
  organization: Duke University School of Medicine
BackLink https://www.ncbi.nlm.nih.gov/pubmed/30907005$$D View this record in MEDLINE/PubMed
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ContentType Journal Article
Copyright 2019 The Authors. published by Wiley Periodicals, Inc.
2019 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.
2019. This work is published under http://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.
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Issue 5
Keywords bioprosthetic valves
atrial fibrillation
apixaban
valve repair
Language English
License Attribution
2019 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.
This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
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Notes Funding information
Bristol‐Myers Squibb; Pfizer
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These authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Michael Hanna is the Employee of Bristol‐Myers Squibb at the time of study conduct.
Funding information Bristol‐Myers Squibb; Pfizer
ORCID 0000-0003-2999-4961
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PublicationTitle Clinical cardiology (Mahwah, N.J.)
PublicationTitleAlternate Clin Cardiol
PublicationYear 2019
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John Wiley & Sons, Inc
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References 2017; 135
2014; 35
2011; 365
2015; 132
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References_xml – volume: 135
  start-page: 714
  year: 2017
  end-page: 716
  article-title: Direct oral anticoagulants in patients with atrial fibrillation and valvular heart disease other than significant mitral stenosis and mechanical valves: a meta‐analysis
  publication-title: Circulation
– volume: 132
  start-page: 624
  year: 2015
  end-page: 632
  article-title: Apixaban in comparison with warfarin in patients with atrial fibrillation and valvular heart disease: findings from the apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation (ARISTOTLE) trial
  publication-title: Circulation
– volume: 35
  start-page: 3328
  year: 2014
  end-page: 3335
  article-title: What is 'valvular' atrial fibrillation? A reappraisal
  publication-title: Eur Heart J
– volume: 365
  start-page: 981
  year: 2011
  end-page: 992
  article-title: Apixaban versus warfarin in patients with atrial fibrillation
  publication-title: N Engl J Med
– volume: 135
  start-page: 1273
  year: 2017
  end-page: 1275
  article-title: Edoxaban for the prevention of thromboembolism in patients with atrial fibrillation and bioprosthetic valves
  publication-title: Circulation
– ident: e_1_2_6_3_1
  doi: 10.1161/CIRCULATIONAHA.116.026793
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  doi: 10.1056/NEJMoa1107039
– ident: e_1_2_6_6_1
  doi: 10.1161/CIRCULATIONAHA.114.014807
– ident: e_1_2_6_2_1
  doi: 10.1093/eurheartj/ehu352
– ident: e_1_2_6_4_1
  doi: 10.1161/CIRCULATIONAHA.116.026714
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Snippet Background The optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair...
The optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair remains...
BackgroundThe optimal anticoagulation strategy for patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) replacement or native valve repair...
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SubjectTerms Aged
Anticoagulants
Anticoagulants - adverse effects
Anticoagulants - therapeutic use
apixaban
atrial fibrillation
Atrial Fibrillation - complications
Atrial Fibrillation - diagnosis
Atrial Fibrillation - drug therapy
Bioprosthesis
bioprosthetic valves
Cardiac arrhythmia
Catheters
Clinical Investigations
Factor Xa Inhibitors - adverse effects
Factor Xa Inhibitors - therapeutic use
Female
Heart Valve Prosthesis
Heart Valve Prosthesis Implantation - adverse effects
Heart Valve Prosthesis Implantation - instrumentation
Heart Valves - surgery
Hemorrhage - chemically induced
Humans
Male
Middle Aged
Pyrazoles - adverse effects
Pyrazoles - therapeutic use
Pyridones - adverse effects
Pyridones - therapeutic use
Risk Factors
Stroke - diagnosis
Stroke - etiology
Stroke - prevention & control
Time Factors
Treatment Outcome
valve repair
Warfarin - adverse effects
Warfarin - therapeutic use
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Title Efficacy and safety of apixaban vs warfarin in patients with atrial fibrillation and prior bioprosthetic valve replacement or valve repair: Insights from the ARISTOTLE trial
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