CLINICAL RESEARCH: HEART RHYTHM DISORDER
Incidence of Stroke in Paroxysmal Versus Sustained Atrial Fibrillation in Patients Taking Oral Anticoagulation or Combined Antiplatelet TherapyAn ACTIVE W Substudy
Stefan H. Hohnloser, MD, FACC*,*,
Dimitri Pajitnev, MD*,
Janice Pogue, PhD ,
Jeff S. Healey, MD,
Marc A. Pfeffer, MD, FACC ,
Salim Yusuf, MD, FACC,
Stuart J. Connolly, MD, FACC for the ACTIVE W Investigators
* Department of Cardiology, Division of Electrophysiology, J. W. Goethe University, Frankfurt, Germany
Department of Medicine, McMaster University, Hamilton, Ontario, Canada
Brigham and Women’s Hospital, Boston, Massachusetts.
Manuscript received May 24, 2007;
revised manuscript received July 10, 2007,
accepted July 24, 2007.
* Reprint requests and correspondence: Dr. Stefan H. Hohnloser, J. W. Goethe University, Department of Cardiology, Division of Electrophysiology, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany. (Email: Hohnloser{at}em.uni-frankfurt.de).
Objectives: Our goal was to determine the risk of stroke or non-cerebral embolism associated with paroxysmal compared with sustained atrial fibrillation (AF).
Background: The risk of stroke and non-cerebral embolism and the efficacy of oral anticoagulation (OAC) in paroxysmal AF as compared with sustained AF are not precisely known.
Methods: The ACTIVE W (Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events) was a trial comparing OAC to combined antiplatelet therapy with aspirin and clopidogrel for prevention of vascular events in 6,706 AF patients. The incidence of thromboembolic events and major bleeds were compared in patients with paroxysmal AF (n = 1,202) and persistent or permanent AF (n = 5,495).
Results: Patients with paroxysmal AF were younger, had a shorter AF history, more hypertension, and less valvular disease, heart failure, and diabetes mellitus than patients with sustained AF. At baseline, patients with paroxysmal AF had a CHADS2 (cardiac failure, hypertension, age, diabetes, stroke [doubled]) risk score of 1.79 ± 1.03 compared with 2.04 ± 1.12 in patients with sustained AF (p < 0.00001). The annualized risk of stroke or non-central nervous system (CNS) systemic embolism was 2.0 in paroxysmal AF compared with 2.2 in sustained AF (relative risk 0.87, 95% confidence interval [CI] 0.59 to 1.30, p = 0.496). After adjusting for confounding baseline variables, the relative risk was 0.94 (95% CI 0.63 to 1.40, p = 0.755). The incidence of stroke and non-CNS embolism was lower for patients treated with OAC irrespective of type of AF. There were more bleedings of any type in patients receiving clopidogrel plus aspirin, irrespective of the type of AF.
Conclusions: Patients with paroxysmal AF treated with aspirin plus clopidogrel or OAC have a similar risk for thromboembolic events than patients with sustained AF. This risk can be significantly lowered with OAC. (The ACTIVE W trial; http://www.clinicaltrials.gov/ct/show/NCT00243178
[ClinicalTrials.gov]
; NCT00243178)
|
Abbreviations and Acronyms
| | AF = atrial fibrillation | | CI = confidence interval | | CNS = central nervous system | | INR = international normalized ratio | | OAC = oral anticoagulation | | RR = relative risk |
|
This article has been cited by other articles:
|
|
|
|
 
T. V. Glotzer, E. G. Daoud, D. G. Wyse, D. E. Singer, M. D. Ezekowitz, C. Hilker, C. Miller, D. Qi, and P. D. Ziegler
The Relationship Between Daily Atrial Tachyarrhythmia Burden From Implantable Device Diagnostics and Stroke Risk: The TRENDS Study
Circ Arrhythm Electrophysiol,
October 1, 2009;
2(5):
474 - 480.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Suissa, D. Bertora, S. Lachaud, and M. H. Mahagne
Score for the Targeting of Atrial Fibrillation (STAF): A New Approach to the Detection of Atrial Fibrillation in the Secondary Prevention of Ischemic Stroke
Stroke,
August 1, 2009;
40(8):
2866 - 2868.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Kirchhof, J. Bax, C. Blomstrom-Lundquist, H. Calkins, A. J. Camm, R. Cappato, F. Cosio, H. Crijns, H.-C. Diener, A. Goette, et al.
Early and comprehensive management of atrial fibrillation: Proceedings from the 2nd AFNET/EHRA consensus conference on atrial fibrillation entitled 'research perspectives in atrial fibrillation'
Europace,
July 1, 2009;
11(7):
860 - 885.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. G. Hart and L. A. Pearce
Current Status of Stroke Risk Stratification in Patients With Atrial Fibrillation
Stroke,
July 1, 2009;
40(7):
2607 - 2610.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Kirchhof, J. Bax, C. Blomstrom-Lundquist, H. Calkins, A. John Camm, R. Cappato, F. Cosio, H. Crijns, H.-C. Diener, A. Goette, et al.
Early and comprehensive management of atrial fibrillation: executive summary of the proceedings from the 2nd AFNET-EHRA consensus conference 'research perspectives in AF'
Eur. Heart J.,
June 17, 2009;
(2009)
ehp235v1.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Friberg, N. Hammar, and M. Rosenqvist
Stroke in paroxysmal atrial fibrillation: report from the Stockholm Cohort of Atrial Fibrillation
Eur. Heart J.,
January 27, 2009;
(2009)
ehn599v1.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Nieuwlaat and S. J Connolly
Stroke prevention in atrial fibrillation: better use of anticoagulation and new agents will lead to improved outcomes
Heart,
January 15, 2009;
95(2):
95 - 97.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. J. Camm, P. Kirchhof, G. Y.H. Lip, I. Savelieva, and S. Ernst
CHAPTER 29 Atrial Fibrillation
ESC Textbook of Cardiovascular Medicine,
January 1, 2009;
2(1):
med-9780199566990-chapter - med-9780199566990-chapter.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. H. Hohnloser, G. Z. Duray, U. Baber, and J. L. Halperin
Prevention of stroke in patients with atrial fibrillation: current strategies and future directions
Eur. Heart J. Suppl.,
September 1, 2008;
10(suppl_H):
H4 - H10.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Stramba-Badiale
Atrial fibrillation subtypes, risk of stroke, and antithrombotic therapy
Eur. Heart J.,
April 1, 2008;
29(7):
840 - 842.
[Full Text]
[PDF]
|
|
|
|
