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m. 86% with the total populationhad a CHADS2 score of 3 or higher.Individuals were randomised to rivaroxaban 20 mgonce daily, or dose-adjusted warfarintitrated to a target INR of 2.5. The per-protocol, astreatedprimary analysis was designed to determinewhether rivaroxaban was noninferior histone deacetylase inhibitor to warfarin forthe major end point of stroke or systemic embolism;when the noninferiority criteria were satisfied, then superioritywas analysed within the intent-to-treat population.Rivaroxaban was equivalent to warfarin for the primaryefficacy endpoint of prevention of stroke andsystemic embolism. The stricterintention-to-treat analysis also showed rivaroxabanwas equivalent to warfarin but did not reach statisticalsignificance for superiority: event rate 2.12 versus2.42 per 100 patient years for rivaroxaban versuswarfarin; HR 0.
88, 95% CI 0.74–1.03, P ??0.117 forsuperiority. Superiority was only demonstrated in theper-protocol analysis of individuals who continued toreceive therapy for the 40-month trial period: eventrate histone deacetylase inhibitor 1.70 versus 2.15 per 100 patient years for rivaroxabanversus warfarin; HR 0.79, 95% CI 0.65–0.95,P ??0.015 for superiority.Key and nonmajor clinically relevant bleedingwas equivalent with rivaroxaban and warfarin:event rate 14.91 versus 14.52 per 100 patient yearsfor rivaroxaban versus warfarin; HR 1.03, 95% CI0.96–1.11, P ??0.442. The rivaroxaban group demonstratedsignificantly much less fatal bleeding, intracranial haemorrhage. Nevertheless, significantlymore individuals receiving rivaroxaban had a haemoglobindecrease of 2 g/dL or moreand necessary a blood transfusion.
The number of individuals experiencing a seriousadverse event was equivalent within the two groupsas IEM 1754 was thedocumentation of an adverse event requiring discontinuationof the study drug. Premature discontinuation rateswere also comparable, at roughly 23%. A higherpercentage of individuals taking rivaroxaban experiencedepistaxis, and the rates of ALTelevation were exactly the same in both groups.ApixabanThe AVERROES study was designed to evaluate theuse of apixaban for stroke prophylaxis by comparingit to aspirin in individuals unsuitable for warfarin.111 Thestudy enrolled 5600 individuals with AF who were eitherintolerant of or unsuitable for warfarin and comparedapixaban 5 mg twice dailywith aspirin 81–324 mg/day.The study was prematurely due to an acceptablesafety profile and benefit in favour of apixaban.
Aftera year, individuals taking apixaban were identified to havea 55% reduction within the major endpoint of strokeor systemic embolism. The rate ofmajor PARP bleeding was equivalent in both groups: 1.4% peryear for apixaban and 1.2% per year for aspirin. Aspirin was theless well-tolerated therapy.112The ARISTOTLE trial has compared apixaban towarfarin in individuals with atrial fibrillation.113 It is arandomised phase III, double-blind, international trialcomparing apixaban 5 mg twice/day versus warfarintitrated to an INR between 2 and 3 in over 18,000patients.114 The major outcome was strokeor systemic embolism,and the trial was designed to test for noninferiority.Secondary objectives integrated an analysis for superioritywith respect towards the major outcome and to therates of IEM 1754 significant bleeding and all-cause mortality.
Thefollow-up period was 1.8 years.The histone deacetylase inhibitor rate with the major outcome in ARISTOTLEwas 1.27% per year within the apixaban group versus1.60% per year within the warfarin group. This was primarily driven by a reductionin haemorrhagic stroke, as the rates of ischaemicstroke were comparable with warfarin: 0.97% peryear within the apixaban group versus 1.05% per year inthe warfarin group. Conversely, rate of haemorrhagicstroke was 0.24% per year within the apixaban groupversus 0.47% per year within the warfarin group. Apixabandemonstrated a benefit with regards to all-causemortality in comparison with warfarin: rates of death fromany cause were 3.52% within the apixaban group versus3.94% within the warfarin group. Apixaban was identified tobe safer than warfarin in regard to significant bleeding:2.13% per year within the apixaban group versus 3.
09%per year within the warfarin group. Drug discontinuationoccurred much less frequently with apixaban compared towarfarin: 25.3% versus 27.5%. The averagetime spent in therapeutic INR was 62.2% for thewarfarin-treated individuals. The reported adverse andserious adverse effects were equivalent in both groupsof individuals.Patient Values and PreferencesAn crucial consideration IEM 1754 when deciding on a therapeuticstrategy for stroke prophylaxis in patientswith AF is that of patient preference. Individuals will,normally speaking, be taking the prescribed therapiesfor the duration of their lives so it truly is crucialthat they're adequately informed. Evidence suggeststhat well-informed individuals are much more compliantwith therapy115 and have superior outcomes.116 The predominantconcern of individuals is that of stroke,117 andmany are willing to accept slightly increased bleedingrisks to avoid a stroke. Physicians have a tendency to bemore concerned with hospital admissions, whereaspatients are in the end worried about death.118 TheAF-AWARE study also identified that