Bleeding during treatment with aspirin versus apixaban in patients with atrial fibrillation unsuitable for warfarin: the apixaban versus acetylsalicylic acid to prevent stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment (AVERROES) trial

Stroke. 2012 Dec;43(12):3291-7. doi: 10.1161/STROKEAHA.112.664144. Epub 2012 Oct 2.


Background and purpose: Apixaban reduces stroke with comparable bleeding risks when compared with aspirin in patients with atrial fibrillation who are unsuitable for vitamin k antagonist therapy. This analysis explores patterns of bleeding and defines bleeding risks based on stroke risk with apixaban and aspirin.

Methods: The Apixaban versus Acetylsalicylic Acid to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin k Antagonist Treatment (AVERROES) trial randomized 5599 patients with atrial fibrillation and risk factors to receive either apixaban or aspirin. Bleeding events were defined as the first occurrence of either major bleeding or clinically relevant nonmajor bleeding.

Results: The rate of a bleeding event was 3.8%/year with aspirin and 4.5%/year with apixaban (hazard ratio with apixaban, 1.18; 95% CI, 0.92-1.51; P=0.19). The anatomic site of bleeding did not differ between therapies. Risk factors for bleeding common to apixaban and aspirin were use of nonstudy aspirin>50% of the time and a history of daily/occasional nosebleeds. The rates of both stroke and bleeding increased with higher CHADS2 scores but apixaban compared with aspirin was associated with a similar relative risk of bleeding (P interaction 0.21) and a reduced relative risk of stroke (P interaction 0.37) irrespective of CHADS2 category.

Conclusions: Anatomic sites and predictors of bleeding are similar for apixaban and aspirin in these patients. Higher CHADS2 scores are associated with increasing rates of bleeding and stroke, but the balance between risks and benefits of apixaban compared with aspirin is favorable irrespective of baseline stroke risk. Clinical Trial Registration Information- Unique identifier: NCT 00496769.

Trial registration: NCT00496769.

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anticoagulants
  • Aspirin / administration & dosage
  • Aspirin / adverse effects*
  • Atrial Fibrillation / drug therapy*
  • Atrial Fibrillation / epidemiology
  • Brain Ischemia / drug therapy
  • Brain Ischemia / epidemiology
  • Brain Ischemia / prevention & control
  • Cerebral Hemorrhage / chemically induced*
  • Cerebral Hemorrhage / epidemiology
  • Contraindications
  • Female
  • Fibrinolytic Agents / administration & dosage
  • Fibrinolytic Agents / adverse effects
  • Follow-Up Studies
  • Humans
  • Male
  • Platelet Aggregation Inhibitors / administration & dosage
  • Platelet Aggregation Inhibitors / adverse effects
  • Pyrazoles / administration & dosage
  • Pyrazoles / adverse effects*
  • Pyridones / administration & dosage
  • Pyridones / adverse effects*
  • Risk Factors
  • Stroke / drug therapy
  • Stroke / epidemiology
  • Stroke / prevention & control*
  • Vitamin K / antagonists & inhibitors
  • Warfarin


  • Anticoagulants
  • Fibrinolytic Agents
  • Platelet Aggregation Inhibitors
  • Pyrazoles
  • Pyridones
  • Vitamin K
  • apixaban
  • Warfarin
  • Aspirin

Associated data