title: Stroke risk and efficacy of apixaban in atrial fibrillation patients with moderate chronic kidney disease.
abstract: BACKGROUND
  Apixaban is superior to aspirin for the prevention of stroke in patients with atrial fibrillation. Apixaban is partially renally excreted and may accumulate in patients with renal impairment.
  
  
  METHODS
  We evaluated the efficacy and safety of apixaban 5 mg twice daily (2.5 mg twice daily in selected patients) compared with aspirin 81 to 324 mg daily in 1697 patients with stage III chronic kidney disease (CKD) enrolled in 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. Primary outcome was all stroke and non-central nervous system emboli.
  
  
  RESULTS
  Compared with patients with estimated glomerular filtration rates (eGFRs) ≥60 mL/min per 1.73 m2, stage III CKD patients (n = 1697; 30% of the cohort; mean eGFR 49 mL/min per 1.73 m2) were older (mean age 75 v 68 years) with more frequent hypertension, diabetes, heart failure, and previous stroke (all P < .01). Stage III CKD was an independent predictor of primary events (hazard ratio [HR] 1.6; P = .01) and major hemorrhage (HR 2.2; P = .02). Apixaban significantly reduced primary events by 68% (5.6% per year on aspirin v 1.8% per year on apixaban; HR 0.32; 95% confidence interval [CI] 0.18-0.55; P < .001) for stage III CKD participants and by 43% (2.8% per year on aspirin v 1.6% per year on apixaban; HR 0.57; 95% CI 0.37-0.87; P = .009) for patients with eGFRs ≥60 mL/min per 1.73 m2 (P for interaction = .10). There was no significant difference in major hemorrhage in stage III CKD patients by treatment: 2.2% per year with aspirin versus 2.5% per year with apixaban (HR 1.2; 95% CI 0.65-2.1).
  
  
  CONCLUSIONS
  Stage III CKD was an independent predictor of stroke in atrial fibrillation patients taking aspirin. Among stage III CKD patients, apixaban significantly reduced stroke relative to aspirin without a significant increase in major hemorrhage.
authors: Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.
authors: John W
authors: JW
authors: Eikelboom
authors: Stuart J
authors: SJ
authors: Connolly
authors: Peggy
authors: P
authors: Gao
authors: Ernesto
authors: E
authors: Paolasso
authors: Raffaele
authors: R
authors: De Caterina
authors: Steen
authors: S
authors: Husted
authors: Martin
authors: M
authors: O'Donnell
authors: Salim
authors: S
authors: Yusuf
authors: Robert G
authors: RG
authors: Hart
mesh_terms: D000368:Aged; D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D015415:Biomarkers / Q000097:blood; D016009:Chi-Square Distribution; D003404:Creatinine / Q000097:blood; D004311:Double-Blind Method; D004617:Embolism / Q000209:etiology / Q000517:prevention & control*; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000378:metabolism / Q000627:therapeutic use*; D005919:Glomerular Filtration Rate; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D007668:Kidney / Q000378:metabolism / Q000503:physiopathology; D008297:Male; D016016:Proportional Hazards Models; D011720:Pyrazoles / Q000009:adverse effects / Q000378:metabolism / Q000627:therapeutic use*; D011728:Pyridones / Q000009:adverse effects / Q000378:metabolism / Q000627:therapeutic use*; D051436:Renal Insufficiency, Chronic / Q000097:blood / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D005343:Fibrinolytic Agents; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D003404:Creatinine; D001241:Aspirin