title: Bleeding during treatment with aspirin versus apixaban in patients with atrial fibrillation unsuitable for warfarin: 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.
abstract: OBJECTIVE
  Apixaban reduces stroke with comparable bleeding risks when compared with aspirin in patients with atrial fibrillation who are unsuitable for vitamin k antagonist therapy. This analysis explores patterns of bleeding and defines bleeding risks based on stroke risk with apixaban and aspirin.
  
  
  METHODS
  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 randomized 5599 patients with atrial fibrillation and risk factors to receive either apixaban or aspirin. Bleeding events were defined as the first occurrence of either major bleeding or clinically relevant nonmajor bleeding.
  
  
  RESULTS
  The rate of a bleeding event was 3.8%/year with aspirin and 4.5%/year with apixaban (hazard ratio with apixaban, 1.18; 95% CI, 0.92-1.51; P=0.19). The anatomic site of bleeding did not differ between therapies. Risk factors for bleeding common to apixaban and aspirin were use of nonstudy aspirin>50% of the time and a history of daily/occasional nosebleeds. The rates of both stroke and bleeding increased with higher CHADS2 scores but apixaban compared with aspirin was associated with a similar relative risk of bleeding (P interaction 0.21) and a reduced relative risk of stroke (P interaction 0.37) irrespective of CHADS2 category.
  
  
  CONCLUSIONS
  Anatomic sites and predictors of bleeding are similar for apixaban and aspirin in these patients. Higher CHADS2 scores are associated with increasing rates of bleeding and stroke, but the balance between risks and benefits of apixaban compared with aspirin is favorable irrespective of baseline stroke risk. Clinical Trial Registration Information- www.clinicaltrials.gov. Unique identifier: NCT 00496769.
authors.affiliation: University of Missouri-Columbia, Five Hospital Drive, CE306, Columbia, MO 65212, USA. flakerg@health.missouri.edu
authors.forename: Greg C
authors.initials: GC
authors.lastname: Flaker
authors.forename: John W
authors.initials: JW
authors.lastname: Eikelboom
authors.forename: Olga
authors.initials: O
authors.lastname: Shestakovska
authors.forename: Stuart J
authors.initials: SJ
authors.lastname: Connolly
authors.forename: Scott
authors.initials: S
authors.lastname: Kaatz
authors.forename: Andrzej
authors.initials: A
authors.lastname: Budaj
authors.forename: Steen
authors.initials: S
authors.lastname: Husted
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.forename: Robert G
authors.initials: RG
authors.lastname: Hart
mesh_terms: D000368:Aged; D000925:Anticoagulants; D001241:Aspirin / Q000008:administration & dosage / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000453:epidemiology; D002545:Brain Ischemia / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control; D002543:Cerebral Hemorrhage / Q000139:chemically induced* / Q000453:epidemiology; D000075202:Contraindications; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D011720:Pyrazoles / Q000008:administration & dosage / Q000009:adverse effects*; D011728:Pyridones / Q000008:administration & dosage / Q000009:adverse effects*; D012307:Risk Factors; D020521:Stroke / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control*; D014812:Vitamin K / Q000037:antagonists & inhibitors; D014859:Warfarin
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D011720:Pyrazoles; D011728:Pyridones; D014812:Vitamin K; C522181:apixaban; D014859:Warfarin; D001241:Aspirin