title: Apixaban in patients with atrial fibrillation and prior coronary artery disease: insights from the ARISTOTLE trial.
abstract: BACKGROUND
  A substantial portion of patients with atrial fibrillation (AF) also have coronary artery disease (CAD) and are at risk for coronary events. Warfarin is known to reduce these events, but increase the risk of bleeding. We assessed the effects of apixaban compared with warfarin in AF patients with and without prior CAD.
  
  
  RESULTS
  In ARISTOTLE, 18,201 patients with AF were randomized to apixaban or warfarin. History of CAD was defined as documented CAD, prior myocardial infarction, and/or history of coronary revascularization. We analyzed baseline characteristics and clinical outcomes of patients with and without prior CAD and compared outcomes by randomized treatment using Cox models. A total of 6639 (36.5%) patients had prior CAD. These patients were more often male, more likely to have prior stroke, diabetes, and hypertension, and more often received aspirin at baseline (42.2% vs. 24.5%). The effects of apixaban were similar among patients with and without prior CAD on reducing stroke or systemic embolism and death from any cause (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.71-1.27, P for interaction=0.12; HR 0.96, 95% CI 0.81-1.13, P for interaction=0.28). Rates of myocardial infarction were numerically lower with apixaban than warfarin among patients with and without prior CAD. The effect of apixaban on reducing major bleeding and intracranial hemorrhage was consistent in patients with and without CAD.
  
  
  CONCLUSIONS
  In patients with AF, apixaban more often prevented stroke or systemic embolism and death and caused less bleeding than warfarin, regardless of the presence of prior CAD. Given the common occurrence of AF and CAD and the higher rates of cardiovascular events and death, our results indicate that apixaban may be a better treatment option than warfarin for these high-risk patients.
authors.affiliation: ECLA Estudios Cardiológicos Latinoamérica, Rosario, Argentina.
authors.forename: Maria Cecilia
authors.initials: MC
authors.lastname: Bahit
authors.forename: Renato D
authors.initials: RD
authors.lastname: Lopes
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Wojdyla
authors.forename: Stefan H
authors.initials: SH
authors.lastname: Hohnloser
authors.forename: John H
authors.initials: JH
authors.lastname: Alexander
authors.forename: Basil S
authors.initials: BS
authors.lastname: Lewis
authors.forename: Philip E
authors.initials: PE
authors.lastname: Aylward
authors.forename: Freek W A
authors.initials: FW
authors.lastname: Verheugt
authors.forename: Matyas
authors.initials: M
authors.lastname: Keltai
authors.forename: Rafael
authors.initials: R
authors.lastname: Diaz
authors.forename: Michael
authors.initials: M
authors.lastname: Hanna
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Granger
authors.forename: Lars
authors.initials: L
authors.lastname: Wallentin
mesh_terms: D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000188:drug therapy* / Q000401:mortality*; D003324:Coronary Artery Disease / Q000188:drug therapy* / Q000401:mortality*; D004617:Embolism / Q000401:mortality / Q000517:prevention & control; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000009:adverse effects; D006470:Hemorrhage / Q000139:chemically induced / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011720:Pyrazoles / Q000008:administration & dosage* / Q000009:adverse effects; D011728:Pyridones / Q000008:administration & dosage* / Q000009:adverse effects; D012307:Risk Factors; D020521:Stroke / Q000401:mortality / Q000517:prevention & control; D016896:Treatment Outcome; D014859:Warfarin / Q000008:administration & dosage* / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D014859:Warfarin
keywords: Apixaban; Atrial fibrillation; Coronary artery disease; Warfarin