Left ventricular systolic dysfunction, heart failure, and the risk of stroke and systemic embolism in patients with atrial fibrillation: insights from the ARISTOTLE trial.

Published

Journal Article

BACKGROUND: We examined the risk of stroke or systemic embolism (SSE) conferred by heart failure (HF) and left ventricular systolic dysfunction (LVSD) in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation Trial (ARISTOTLE), as well as the effect of apixaban versus warfarin. METHODS AND RESULTS: The risk of a number of outcomes, including the composite of SSE or death (to take account of competing risks) and composite of SSE, major bleeding, or death (net clinical benefit) were calculated in 3 patient groups: (1) no HF/no LVSD (n=8728), (2) HF/no LVSD (n=3207), and (3) LVSD with/without symptomatic HF (n=2736). The rate of both outcomes was highest in patients with LVSD (SSE or death 8.06; SSE, major bleeding, or death 10.46 per 100 patient-years), intermediate for HF but preserved LV systolic function (5.32; 7.24), and lowest in patients without HF or LVSD (1.54; 5.27); each comparison P<0.0001. Each outcome was less frequent in patients treated with apixaban: in all ARISTOTLE patients, the apixaban/warfarin hazard ratio for SSE or death was 0.89 (95% confidence interval, 0.81-0.98; P=0.02); for SSE, major bleed, or death it was 0.85 (0.78-0.92; P<0.001). There was no heterogeneity of treatment effect across the 3 groups. CONCLUSIONS: Patients with LVSD (with/without HF) had a higher risk of SSE or death (but similar rate of SSE) compared with patients with HF but preserved LV systolic function; both had a greater risk than patients without either HF or LVSD. Apixaban reduced the risk of both outcomes more than warfarin in all 3 patient groups. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412984.

Full Text

Duke Authors

Cited Authors

  • McMurray, JJV; Ezekowitz, JA; Lewis, BS; Gersh, BJ; van Diepen, S; Amerena, J; Bartunek, J; Commerford, P; Oh, B-H; Harjola, V-P; Al-Khatib, SM; Hanna, M; Alexander, JH; Lopes, RD; Wojdyla, DM; Wallentin, L; Granger, CB; ARISTOTLE Committees and Investigators,

Published Date

  • May 2013

Published In

Volume / Issue

  • 6 / 3

Start / End Page

  • 451 - 460

PubMed ID

  • 23575255

Pubmed Central ID

  • 23575255

Electronic International Standard Serial Number (EISSN)

  • 1941-3297

International Standard Serial Number (ISSN)

  • 1941-3289

Digital Object Identifier (DOI)

  • 10.1161/circheartfailure.112.000143

Language

  • eng