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

Stroke. 2017 Dec;48(12):3266-3273. doi: 10.1161/STROKEAHA.117.017574. Epub 2017 Oct 31.

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.

Keywords: apixaban; atrial fibrillation; echocardiography; risk factors; warfarin.

Publication types

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

MeSH terms

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

Substances

  • Anticoagulants
  • Pyrazoles
  • Pyridones
  • apixaban
  • Warfarin

Associated data

  • ClinicalTrials.gov/NCT00412984