title: Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF).
abstract: BACKGROUND
  Nonvalvular atrial fibrillation is common in elderly patients, who face an elevated risk of stroke but difficulty sustaining warfarin treatment. The oral factor Xa inhibitor rivaroxaban was noninferior to warfarin in the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). This prespecified secondary analysis compares outcomes in older and younger patients.
  
  
  RESULTS
  There were 6229 patients (44%) aged ≥75 years with atrial fibrillation and ≥2 stroke risk factors randomized to warfarin (target international normalized ratio=2.0-3.0) or rivaroxaban (20 mg daily; 15 mg if creatinine clearance <50 mL/min), double blind. The primary end point was stroke and systemic embolism by intention to treat. Over 10 866 patient-years, older participants had more primary events (2.57% versus 2.05%/100 patient-years; P=0.0068) and major bleeding (4.63% versus 2.74%/100 patient-years; P<0.0001). Stroke/systemic embolism rates were consistent among older (2.29% rivaroxaban versus 2.85% warfarin per 100 patient-years; hazard ratio=0.80; 95% confidence interval, 0.63-1.02) and younger patients (2.00% versus 2.10%/100 patient-years; hazard ratio=0.95; 95% confidence interval, 0.76-1.19; interaction P=0.313), as were major bleeding rates (≥75 years: 4.86% rivaroxaban versus 4.40% warfarin per 100 patient-years; hazard ratio=1.11; 95% confidence interval, 0.92-1.34; <75 years: 2.69% versus 2.79%/100 patient-years; hazard ratio=0.96; 95% confidence interval, 0.78-1.19; interaction P=0.336). Hemorrhagic stroke rates were similar in both age groups; there was no interaction between age and rivaroxaban response.
  
  
  CONCLUSIONS
  Elderly patients had higher stroke and major bleeding rates than younger patients, but the efficacy and safety of rivaroxaban relative to warfarin did not differ with age, supporting rivaroxaban as an alternative for the elderly.
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.). jonathan.halperin@mssm.edu.
authors.forename: Jonathan L
authors.initials: JL
authors.lastname: Halperin
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Graeme J
authors.initials: GJ
authors.lastname: Hankey
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Wojdyla
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Jonathan P
authors.initials: JP
authors.lastname: Piccini
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Yuliya
authors.initials: Y
authors.lastname: Lokhnygina
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Manesh R
authors.initials: MR
authors.lastname: Patel
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Günter
authors.initials: G
authors.lastname: Breithardt
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Singer
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Richard C
authors.initials: RC
authors.lastname: Becker
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Werner
authors.initials: W
authors.lastname: Hacke
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: John F
authors.initials: JF
authors.lastname: Paolini
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Nessel
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.affiliation: From Icahn School of Medicine at Mount Sinai, New York, NY (J.L.H.); School of Medicine and Pharmacology, University of Western Australia School of Medicine and Pharmacology, Perth, Australia (G.J.H.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (D.M.W., J.P.P., Y.L., M.R.P.); University of Münster, Münster, Germany (G.B.); Massachusetts General Hospital and Harvard Medical School, Boston, MA (D.E.S.); University of Cincinnati College of Medicine, Cincinnati, OH (R.C.B.); Ruprecht-Karls University, Heidelberg, Germany (W.H.); Cerenis Therapeutics, Labege, France (J.F.P.); Janssen Research and Development, Raritan, NJ (C.C.N.); Stanford University School of Medicine, Stanford, CA (K.W.M.); Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC (R.M.C.); and University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom (K.A.A.F.).
authors.forename: Keith A A
authors.initials: KA
authors.lastname: Fox
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D004311:Double-Blind Method; D004617:Embolism / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D065427:Factor Xa Inhibitors; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000175:diagnosis; D006801:Humans; D008297:Male; D008875:Middle Aged; D009025:Morpholines / Q000008:administration & dosage* / Q000009:adverse effects; D000069552:Rivaroxaban; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D013876:Thiophenes / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome; D014812:Vitamin K / Q000037:antagonists & inhibitors*; D014859:Warfarin / Q000008:administration & dosage* / Q000009:adverse effects
chemical_list: D000925:Anticoagulants; D065427:Factor Xa Inhibitors; D009025:Morpholines; D013876:Thiophenes; D014812:Vitamin K; D014859:Warfarin; D000069552:Rivaroxaban
keywords: aging; anticoagulant; elderly; hemorrhage; stroke