Efficacy and Safety of Apixaban Compared With Warfarin in Patients With Atrial Fibrillation and Peripheral Artery Disease: Insights From the ARISTOTLE Trial

Peter T Hu, Renato D Lopes, Susanna R Stevens, Lars Wallentin, Laine Thomas, John H Alexander, Michael Hanna, Basil S Lewis, Freek W A Verheugt, Christopher B Granger, W Schuyler Jones, Peter T Hu, Renato D Lopes, Susanna R Stevens, Lars Wallentin, Laine Thomas, John H Alexander, Michael Hanna, Basil S Lewis, Freek W A Verheugt, Christopher B Granger, W Schuyler Jones

Abstract

Background: We studied (1) the rates of stroke or systemic embolism and bleeding in patients with atrial fibrillation and peripheral artery disease (PAD) and (2) the efficacy and safety of apixaban versus warfarin in patients with atrial fibrillation with and without PAD.

Methods and results: The Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial randomized 18 201 patients with atrial fibrillation to apixaban or warfarin for stroke/systemic embolism prevention; 884 (4.9%) patients had PAD at baseline. Patients with PAD had higher unadjusted rates of stroke and systemic embolism (hazard ratio [HR] 1.73, 95% CI 1.22-2.45; P=0.002) and major bleeding (HR 1.34, 95% CI 1.00-1.81; P=0.05), but after adjustment, no differences existed in rates of stroke and systemic embolism (HR 1.32, 95% CI 0.93-1.88; P=0.12) and major bleeding (HR 1.03, 95% CI 0.76-1.40; P=0.83) compared with patients without PAD. The risk of stroke or systemic embolism was similar in patients assigned to apixaban and warfarin with PAD (HR 0.63, 95% CI 0.32-1.25) and without PAD (HR 0.80, 95% CI 0.66-0.96; interaction P=0.52). Patients with PAD did not have a statistically significant reduction in major or clinically relevant nonmajor bleeding with apixaban compared with warfarin (HR 1.05, 95% CI 0.69-1.58), whereas those without PAD had a statistically significant reduction (HR 0.65, 95% CI 0.58-0.73; interaction P=0.03).

Conclusions: Patients with PAD in ARISTOTLE had a higher crude risk of stroke or systemic embolism compared with patients without PAD that was not present after adjustment. The benefits of apixaban versus warfarin for stroke and systemic embolism were similar in patients with and without PAD. These findings highlight the need to optimize the treatment of patients with atrial fibrillation and PAD.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412984.

Keywords: apixaban; atrial fibrillation; bleeding; peripheral artery disease; stroke; systemic embolism.

© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1
Figure 1
Treatment effects according to PAD. GUSTO indicates Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries; ISTH, International Society on Thrombosis and Haemostasis; MI, myocardial infarction; PAD indicates peripheral artery disease; TIMI, thrombolysis in myocardial infarction.
Figure 2
Figure 2
Kaplan–Meier plot for cumulative rate of stroke or systemic embolism in patients classified by PAD and treatment assignment. PAD indicates peripheral artery disease.
Figure 3
Figure 3
Kaplan–Meier plot for major or clinically relevant nonmajor bleeding classified by PAD status and treatment assignment. PAD indicates peripheral artery disease.

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