Abstract and Introduction
Abstract
Aims We investigated the prevalence of prior myocardial infarction (MI) and incidence of ischaemic cardiovascular (CV) events among atrial fibrillation (AF) patients.
Methods and results In ROCKET AF, 14 264 patients with nonvalvular AF were randomized to rivaroxaban or warfarin. The key efficacy outcome for these analyses was CV death, MI, and unstable angina (UA). This pre-specified analysis was performed on patients while on treatment. Rates are per 100 patient-years. Overall, 2468 (17%) patients had prior MI at enrollment. Compared with patients without prior MI, these patients were more likely to be male (75 vs. 57%), on aspirin at baseline (47 vs. 34%), have prior congestive heart failure (78 vs. 59%), diabetes (47 vs. 39%), hypertension (94 vs. 90%), higher mean CHADS2 score (3.64 vs. 3.43), and fewer prior strokes or transient ischaemic attacks (46 vs. 54%). CV death, MI, or UA rates tended to be lower in patients assigned rivaroxaban compared with warfarin [2.70 vs. 3.15; hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.73–1.00; P = 0.0509]. CV death, MI, or UA rates were higher in those with prior MI compared with no prior MI (6.68 vs. 2.19; HR 3.04, 95% CI 2.59–3.56) with consistent results for CV death, MI, or UA for rivaroxaban compared with warfarin in prior MI compared with no prior MI (P interaction = 0.10).
Conclusion Prior MI was common and associated with substantial risk for subsequent cardiac events. Patients with prior MI assigned rivaroxaban compared with warfarin had a non-significant 14% reduction of ischaemic cardiac events.
Introduction
Coronary artery disease (CAD) is common in patients with atrial fibrillation (AF). Patients with CAD may develop AF and patients with AF may present with acute coronary syndromes (ACS). Prognostic relevance of AF in patients with acute myocardial infarction (MI) is not certain, with some studies showing an independent increased risk and others not.
Management of patients with AF, ACS, and chronic CAD includes antiplatelet and anticoagulant therapy. Treatment with multiple antiplatelet and anticoagulant agents may be necessary to prevent subsequent thrombotic events, but dual or triple antiplatelet/anticoagulant therapy increases bleeding risk. The bleeding risk may be enhanced in specific patient populations, including the elderly, patients with diabetes, and those with renal insufficiency.
ROCKET AF (Rivaroxaban Once-daily, oral, direct Factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) demonstrated that rivaroxaban, a direct factor Xa inhibitor, was noninferior to warfarin in the prevention of stroke and systemic embolism in high-risk patients. In this report, we investigate the prevalence of established CAD, defined as prior MI, the incidence of cardiovascular (CV) events in a large population of patients with AF receiving anticoagulant therapy, and the risk of CV events with rivaroxaban compared with warfarin.