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Am Heart J. 2018 Mar;197:1-8. doi: 10.1016/j.ahj.2017.09.020. Epub 2017 Oct 24.

Apixaban following acute coronary syndromes in patients with prior stroke: Insights from the APPRAISE-2 trial.

Author information

1
Inova Heart and Vascular Institute, Falls Church, VA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. Electronic address: matthew.sherwood@dm.duke.edu.
2
Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
3
Bristol-Myers Squibb, Princeton, NJ.
4
Stanford University School of Medicine, Stanford, CA.
5
Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
6
Canadian Heart Research Center and University of Toronto, Toronto, Ontario, Canada.
7
Vivantes Neukoelln Medical Center, Berlin, Germany.
8
Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine of the Technion, Haifa, Israel.
9
Harvard Medical School, Boston, MA.

Abstract

BACKGROUND AND PURPOSE:

Patients with prior stroke are at greater risk for recurrent cardiovascular events post-acute coronary syndromes (ACS) and may have a different risk/benefit profile with antithrombotic therapy than patients without prior stroke.

METHODS:

We studied 7391 patients with ACS from APPRAISE-2, stratified by the presence or absence of prior stroke. Baseline characteristics and outcomes of cardiovascular death, myocardial infarction (MI), or stroke were compared between groups. Interactions between prior stroke, treatment assignment (apixaban vs placebo), and outcomes were tested before and after multivariable adjustment with Cox proportional hazards models.

RESULTS:

A total of 902 patients (12%) had prior stroke. Those with prior stroke were older (69 vs 67 years), had more hypertension (91% vs 77%), peripheral vascular disease (22% vs18%), and impaired renal function (38% vs 30%) but less diabetes (44% vs 48%) than those without prior stroke. Patients with prior stroke vs no prior stroke had higher unadjusted rates of cardiovascular death (4.8% vs 4.0%), MI (11.2% vs 7.1%), and ischemic stroke (3.2% vs 0.9%). Patients with prior stroke assigned to apixaban had similar rates of the composite of cardiovascular death, MI, or stroke compared with those assigned to placebo (HR 1.39; 95% CI 0.92-2.08). Patients without prior stroke assigned to apixaban had similar rates of cardiovascular death, MI, or ischemic stroke compared with those assigned to placebo (HR 0.87; 95% CI 0.73-1.04; P-interaction=.041). Median follow-up was 240 days.

CONCLUSIONS:

Patients with prior stroke are at higher risk for recurrent cardiovascular events post-ACS and had a differential risk/benefit profile with oral anticoagulation.

TRIAL REGISTRATION:

ClinicalTrials.gov NCT00831441.

PMID:
29447769
DOI:
10.1016/j.ahj.2017.09.020
[Indexed for MEDLINE]

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