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Apixaban in Patients with Atrial Fibrillation
Open accessAbstract
BACKGROUND: Vitamin K antagonists have been shown to prevent stroke in patients with atrial fibrillation. However, many patients are not suitable candidates for or are unwilling to receive vitamin K antagonist therapy, and these patients have a high risk of stroke. Apixaban, a novel factor Xa inhibitor, may be an alternative treatment for such patients. METHODS: In a double-blind study, we randomly assigned 5599 patients with atrial fibrillation who were at increased risk for stroke and for whom vitamin K antagonist therapy was unsuitable to receive apixaban (at a dose of 5 mg twice daily) or aspirin (81 to 324 mg per day), to determine whether apixaban was superior. The mean follow up period was 1.1 years. The primary outcome was the occurrence of stroke or systemic embolism. RESULTS: Before enrollment, 40% of the patients had used a vitamin K antagonist. The data and safety monitoring board recommended early termination of the study because of a clear benefit in favor of apixaban. There were 51 primary outcome events (1.6% per year) among patients assigned to apixaban and 113 (3.7% per year) among those assigned to aspirin (hazard ratio with apixaban, 0.45; 95% confidence interval [CI], 0.32 to 0.62; P<0.001). The rates of death were 3.5% per year in the apixaban group and 4.4% per year in the aspirin group (hazard ratio, 0.79; 95% CI, 0.62 to 1.02; P=0.07). There were 44 cases of major bleeding (1.4% per year) in the apixaban group and 39 (1.2% per year) in the aspirin group (hazard ratio with apixaban, 1.13; 95% CI, 0.74 to 1.75; P=0.57); there were 11 cases of intracranial bleeding with apixaban and 13 with aspirin. The risk of a first hospitalization for cardiovascular causes was reduced with apixaban as compared with aspirin (12.6% per year vs. 15.9% per year, P<0.001). The treatment effects were consistent among important subgroups. CONCLUSIONS: In patients with atrial fibrillation for whom vitamin K antagonist therapy was unsuitable, apixaban reduced the risk of stroke or systemic embolism without significantly increasing the risk of major bleeding or intracranial hemorrhage. (Funded by Bristol-Myers Squibb and Pfizer; ClinicalTrials.gov number, NCT00496769.).
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“It is superior to no treatment or aspirin in patients with different profiles for stroke risk.”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [354]
In the citing paper
“apixaban significantly reduced stroke or systemic embolism by 55% compared with aspirin, with no significant difference in rates of major bleeding or intracranial haemorrhage.354,403”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [354]
In the citing paper
“Antiplatelet therapy increases bleeding risk, especially dual antiplatelet therapy (2.0% vs. 1.3% with antiplatelet monotherapy; P < 0.001), 433 with bleeding rates that are similar to those on OAC.354,362,431,434”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [354]
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Influential2016 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure
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“The direct thrombin inhibitor, dabigatran, and the factor Xa inhibitor, rivaroxaban, are not recommended in patients with AF and end-stage CKD or on hemodialysis because of the lack of evidence from clinical trials regarding the balance of risks and benefits (74-76, 84-86).”
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“One partial explanation for this finding may be related to the time-in-therapeutic range, which was 68% for PREVAIL versus 64%, 62%, and 55%, respectively, for RE-LY (7), ARISTOTLE (8), and ROCKET AF (9).”
BackgroundEmbolic strokes of undetermined source: the case for a new clinical construct
Hart, R. G., Diener, H., Coutts, S. B., Easton, J. D., Granger, C. B., O'Donnell, M. J., Sacco, R. L., & Connolly, S. J. (2014) · The Lancet Neurology · doi:10.1016/s1474-4422(13)70310-7 · Cited by 1,715
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“Alternatively, a direct thrombin or factor Xa inhibitor can be administered following ablation [392, 393, 395, 396].”
BackgroundMethodGuidelines for the Management of Spontaneous Intracerebral Hemorrhage
Morgenstern, L. B., Hemphill, J. C., Anderson, C. S., Becker, K. J., Broderick, J. P., Connolly, E. S., Greenberg, S. M., Huang, J. N., Macdonald, R. L., Messe, S. R., et al. (2010) · Stroke · doi:10.1161/str.0b013e3181ec611b · Cited by 1,501
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Apixaban for Extended Treatment of Venous Thromboembolism
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“First, a direct thrombin or Factor Xa inhibitor can be administered several hours following ablation.(826,827,853,854) Second, low molecular weight heparin (enoxaparin 0.”
BackgroundSteffel, J., Collins, R., Antz, M., Cornu, P., Desteghe, L., Haeusler, K. G., Oldgren, J., Reinecke, H., Roldan-Schilling, V., Rowell, N., et al. (2021) · EP Europace · doi:10.1093/europace/euab065 · Cited by 1,132
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Apixaban with Antiplatelet Therapy after Acute Coronary Syndrome
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“The Apixaban Versus Acetylsalicylic Acid (ASA) to Prevent Stroke in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment (AVERROES) trial compared apixaban 5 mg bid with aspirin in AF patients who were not candidates for VKA therapy.(125) The trial was stopped early for ben…”
Antithrombotic Therapy for Atrial Fibrillation
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Kozek‐Langenecker, S. A., Afshari, A., Albaladejo, P., Aldecoa, C., ROBERTIS, E. D., Filipescu, D. C., Fries, D. R., Görlinger, K., Haas, T., Imberger, G. L., et al. (2013) · European Journal of Anaesthesiology · doi:10.1097/eja.0b013e32835f4d5b · Cited by 911
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“In the AVERROES (Apixaban Versus Acetylsalicylic Acid to Prevent Strokes in Atrial Fibrillation Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment) study, warfarin-ineligible patients were randomly allocated to either aspirin or the factor Xa inhibitor, apixaban (21).”
MethodGuideline for Reversal of Antithrombotics in Intracranial Hemorrhage
Frontera, J. A., Lewin, J. J., Rabinstein, A. A., Aisiku, I. P., Alexandrov, A. W., Cook, A. M., del Zoppo, G. J., Kumar, M. A., Peerschke, E. I. B., Stiefel, M., et al. (2015) · Neurocritical Care · doi:10.1007/s12028-015-0222-x · Cited by 725
“apixaban, and edoxaban), and secondary prevention of deep venous thrombosis or pulmonary embolism (rivaroxaban and apixaban only) [119–128].”
BackgroundLu, G., DeGuzman, F. R., Hollenbach, S. J., Karbarz, M. J., Abe, K. Y., Lee, G., Luan, P., Hutchaleelaha, A., Inagaki, M., Conley, P. B., et al. (2013) · Nature Medicine · doi:10.1038/nm.3102 · Cited by 700
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“3) and seen in unselected clinical practice.(10,11,30) Those with moderate renal insufficiency have higher CHADS2 values than patients without renal dysfunction (Table 1), hence the importance of testing the randomized comparison of rivaroxaban and warfarin in a population that included a substantial cohort with moder…”
BackgroundApixaban and dalteparin in active malignancy‐associated venous thromboembolism: The ADAM VTE trial
McBane, R. D., Wysokiński, W. E., Le‐Rademacher, J. G., Zemla, T., Ashrani, A. A., Tafur, A. J., Perepu, U. S., Anderson, D. M., Gundabolu, K., Kuzma, C. S., et al. (2019) · Journal of Thrombosis and Haemostasis · doi:10.1111/jth.14662 · Cited by 602
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Emerging concepts in sporadic cerebral amyloid angiopathy
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“For example, apixaban has a similar intracranial bleeding risk profile as aspirin, but is more effective at reducing ischaemic stroke risk (Connolly et al., 2011).”
BackgroundTask Force Members, Lip, G. Y. H., Windecker, S., Huber, K., Kirchhof, P. F., Marín, F. R., ten Berg, J. M., Hæusler, K. G., Boriani, G., Capodanno, D., et al. (2014) · European Heart Journal · doi:10.1093/eurheartj/ehu298 · Cited by 573
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Apixaban versus Enoxaparin for Thromboprophylaxis in Medically Ill Patients
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Off-Label Dosing of Non-Vitamin K Antagonist Oral Anticoagulants and Adverse Outcomes
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Apixaban for Stroke Prevention in Subclinical Atrial Fibrillation
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Friberg, L., Rosenqvist, M., & Lip, G. Y. H. (2012) · Circulation · doi:10.1161/circulationaha.111.055079 · Cited by 454
“Frequent falls, n (%) 9294 (10) 2647 (4) 0.”
Self-citationKakkar, A. K., Mueller, I., Bassand, J., Fitzmaurice, D. A., Goldhaber, S. Z., Goto, S., Haas, S. K., Hacke, W., Lip, G. Y. H., Mantovani, L. G., et al. (2013) · PLoS ONE · doi:10.1371/journal.pone.0063479 · Cited by 449
“Despite mandating the presence of one or more additional stroke risk factors in an effort to exclude patients with lone AF, the GARFIELD population fares as relatively low risk compared with other observational cohorts, and is substantially lower risk than the populations included in randomized trials of novel oral an…”
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
Ponikowski, P. P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G. F., Coats, A. J. S., Falk, V., González‐Juanatey, J. R., Harjola, V., Jankowska, E. A., et al. (2016) · Kardiologia Polska · doi:10.5603/kp.2016.0141 · Cited by 458
Larsen, T. B., Skjøth, F., Nielsen, P. B., Kjældgaard, J. N., & Lip, G. Y. H. (2016) · BMJ · doi:10.1136/bmj.i3189 · Cited by 450
Kamel, H., & Healey, J. S. (2017) · Circulation Research · doi:10.1161/circresaha.116.308407 · Cited by 456
Dabigatran Association With Higher Risk of Acute Coronary Events
Uchino, K. (2012) · Archives of Internal Medicine · doi:10.1001/archinternmed.2011.1666 · Cited by 435
Anticoagulation with Edoxaban in Patients with Atrial High-Rate Episodes
Kirchhof, P. F., Toennis, T., Goette, A., Camm, A. J., Diener, H., Becher, N., Bertaglia, E., Lundqvist, C. B., Borlich, M., Brandes, A., et al. (2023) · New England Journal of Medicine · doi:10.1056/nejmoa2303062 · Cited by 442
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“There is good rationale for reducing the dose of NOACs in patients with a high bleeding risk and/or when a higher plasma level of the drug can be anticipated.(1,7,8) We have chosen an approach with three levels of alert for drug–drug interactions or other clinical factors that may affect NOAC plasma levels or effects…”
BackgroundJanuary, C. T., Wann, L. S., Calkins, H. G., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., et al. (2019) · Heart Rhythm · doi:10.1016/j.hrthm.2019.01.024 · Cited by 414
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Hankey, G. J. (2013) · The Lancet Neurology · doi:10.1016/s1474-4422(13)70255-2 · Cited by 399
Management of venous thrombo-embolism: an update
Konstantinides, S., & Torbicki, A. (2014) · European Heart Journal · doi:10.1093/eurheartj/ehu243 · Cited by 383
Kamel, H., Longstreth, W. T., Tirschwell, D., Kronmal, R. A., Broderick, J. P., Palesch, Y. Y., Meinzer, C., Dillon, C., Ewing, I., Spilker, J. A., et al. (2018) · International Journal of Stroke · doi:10.1177/1747493018799981 · Cited by 380
Eikelboom, J. W., Hirsh, J., Spencer, F. A., Baglin, T. P., & Weitz, J. I. (2012) · CHEST Journal · doi:10.1378/chest.11-2293 · Cited by 389
The Global Burden of Atrial Fibrillation and Stroke
Lip, G. Y. H., Brechin, C. M., & Lane, D. A. (2012) · CHEST Journal · doi:10.1378/chest.11-2888 · Cited by 382
Halvorsen, S., Atar, D., Yang, H., Caterina, R. D., Erol, Ç., Garcia, D., Granger, C. B., Hanna, M., Held, C., Husted, S., et al. (2014) · European Heart Journal · doi:10.1093/eurheartj/ehu046 · Cited by 377
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Parenteral anticoagulants in heart disease: Current status and perspectives (Section II)
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“From the Uppsala Clinical Research Center and Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden (J.O., L.W.); Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., C.A.M., A.G., J.N., S.J.C., S.Y.); Jefferson Medical College, Wynnewood, PA, and Cardiovascular Research F…”
BackgroundInfluentialEHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion – an update
Glikson, M., Wolff, R., Hindricks, G., Mandrola, J. M., Camm, A. J., Lip, G. Y. H., Fauchier, L., Betts, T. R., Lewalter, T., Saw, J., et al. (2020) · EuroIntervention · doi:10.4244/eijy19m08_01 · Cited by 374
Atrial fibrillation in heart failure: what should we do?
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Primary and Secondary Prevention of Ischemic Stroke and Cerebral Hemorrhage
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Vitamin K antagonists in heart disease: Current status and perspectives (Section III)
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications
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Apixaban: A Clinical Pharmacokinetic and Pharmacodynamic Review
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Lip, G. Y. H., Tse, H., & Lane, D. A. (2011) · The Lancet · doi:10.1016/s0140-6736(11)61514-6 · Cited by 347
EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion – an update
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“The evidence for stroke prevention with aspirin is weak [255,258], and it is not as benign as many think, with data suggesting that bleeding rates were similar to apixaban in patients with N-VAF who were deemed ineligible for anticoagulation with warfarin [259].”
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EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion
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Metadata
- Authors
- Connolly, S. J., Eikelboom, J., Joyner, C., Diener, H.-C., Hart, R., Golitsyn, S., Flaker, G., Avezum, A., Hohnloser, S. H., Diaz, R., Talajic, M., Zhu, J., Pais, P., Budaj, A., Parkhomenko, A., Jansky, P., Commerford, P., Tan, R. S., Sim, K.-H., Lewis, B. S., Van Mieghem, W., Lip, G. Y. H., Kim, J. H., Lanas-Zanetti, F., Gonzalez-Hermosillo, A., Dans, A. L., Munawar, M., O'Donnell, M., Lawrence, J., Lewis, G., Afzal, R., & Yusuf, S.
- Affiliations
- Population Health Research Institute (CA)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2011-03-03
- Volume
- 364
- Issue
- 9
- Pages
- 806-817
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2149388786
- Cited by
- 2,483
- References
- 23
- Citations by year
- 2026: 45 · 2025: 54 · 2024: 99 · 2023: 70 · 2022: 71 · 2021: 111 · 2020: 111 · 2019: 119 · 2018: 139 · 2017: 172 · 2016: 215 · 2015: 239 · 2014: 249 · 2013: 310 · 2012: 303
- FWCI
- 223.65
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- UWA Profiles and Research Repository (UWA) (submittedVersion)
- Universitätsbibliographie, Universität Duisburg-Essen (submittedVersion)
- UnissResearch (Università degli Studi di Sassari) (submittedVersion)
- Omeka S (Universidad de La Frontera) (submittedVersion)
- Funders
- Bristol-Myers Squibb
- Eli Lilly and Company
- Pfizer
- AstraZeneca
- GlaxoSmithKline
- Sanofi
- Hamilton Health Sciences
- McMaster University
- Astellas Pharma
- Servier
- Institut de Cardiologie de Montréal
- St. Jude Medical
- Bayer Vital
- Cilag
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
- Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
- Keywords
- apixaban, atrial fibrillation, factor Xa inhibitors, aspirin, stroke prevention, systemic embolism, vitamin K antagonists, major bleeding, intracranial hemorrhage, cardiovascular hospitalization, oral anticoagulation, early trial termination, cardiovascular mortality, cardiovascular risk stratification, subgroup analysis, bleeding risk stratification
- MeSH terms
- Aged, Aged, 80 and over, Aspirin, Atrial Fibrillation, Double-Blind Method, Embolism, Female, Fibrinolytic Agents, Hemorrhage, Humans, Male, Middle Aged, Pyrazoles, Pyridones, Risk Factors, Proportional Hazards Models, Stroke, Factor Xa Inhibitors
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