2MACE score predicts cardiovascular adverse events in real-world atrial fibrillation patients under rivaroxaban therapy. Data from EMIR study

Background

Atrial Fibrillation (AF) patients have higher risk of major adverse cardiovascular events (MACEs). In 2015, the 2MACE score (2 points for metabolic syndrome and age ≥75, and 1 point for myocardial infarction [MI] or revascularization, congestive heart failure [ejection fraction ≤40%] and thromboembolism [stroke or transient ischemic attack]) was described to stratify cardiovascular risk and 2MACE≥3 was related with high risk of MACE in AF patients but a long-term validation in prospective patients under direct anticoagulants has not been performed yet.

The aim of this study was to analyse the incidence of cardiovascular events and to validate the 2MACE score as predictor of MACEs.

Methods

EMIR study [acronym from 'Estudio observacional para la identificaciόn de los factores de riesgo asociados a eventos cardiovasculares Mayores en pacientes con fIbrilaciόn auricular no valvular tratados con un anticoagulante oral directo (Rivaroxaban)'] was an observational, multicenter, post-authorization and prospective study that involved AF patients under oral anticoagulation with rivaroxaban at least 6 months before enrolment. We analyzed baseline clinical characteristics and adverse events after 2.5 years of follow up: annual incidence of thromboembolic events, MACE (composite of nonfatal MI, coronary revascularization and cardiac death) and cardiovascular mortality were analyzed.

Results

We analyzed 1,433 patients (55.5% women, mean 74.2±9.7 years). 385 (26.9%) patients had 2MACE score ≥3 and of those high-risk patients, 42.1% had previous coronary disease, 12.5% had previous peripheral artery disease, 40.7% had diabetes mellitus, 39% heart failure and 50% had chronic kidney disease (GFR<60 ml/min). After 2.5 (2.2–2.6) years of follow-up, we observed patients with 2MACE score ≥3 had higher rate of adverse events (Table), specially of higher rate of cardiovascular mortality and MACE. Patients with 2MACE score ≥3 had RR 4.09 (2.59–6.45; p<0.001) for MACE. Indeed, patients with 2MACE score ≥3 had around 6-fold risk of cardiovascular death due heart failure than patients with 2MACE score <3 (0.17%/year vs 1.09%/year; p=0.003). 2MACE score had suitable predictive performance for MACE (AUC 0.638 [(0.534–0.742); p=0.010).

Conclusion

In a Real-world AF patients under rivaroxaban therapy from EMIR registry, the 2MACE score is a good predictor of long-term cardiovascular events, MACE and major bleeding. A 2MACE score ≥3 categorize patients at “high-risk” with almost 4-fold risk of MACE in a long-term follow-up.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer Hispania S.L. Table 1. Adverse events according to 2MACE

Predictors of adverse clinical outcomes in atrial fibrillation patients with concomitant renal impairment under rivaroxaban therapy

Background

Atrial fibrillation (AF) increases the risk of stroke and mortality, and concomitant renal impairment confers a worse prognosis. However, those factors that may limit the use of direct-acting oral anticoagulants in AF patients with renal impairment have not been further investigated, as they confer a higher risk of adverse events in this patient population.

Purpose

To investigate predictors of adverse clinical outcomes in AF patients with renal impairment who were treated with rivaroxaban.

Methods

The EMIR study is an observational, multicenter study including patients with AF treated with rivaroxaban for at least the previous 6 months. During 2.5 years of follow-up, the occurrence of thromboembolic events (the composite of isquemic stroke, transient ischemic attack, systemic embolism and myocardial infarction [MI]), major bleeding (ISTH definition) and major adverse cardiovascular events (MACE: fatal/non-fatal MI, myocardial revascularization and cardiovascular death) were recorded. For the present analysis, creatinine clearance (CrCl) was estimated by using the Cockroft-Gault equation and renal impairment was defined as a CrCl <60 mL/min.

Results

1433 patients were included (44.5% female; mean age 74.2±9.7 years), of which 498 (35.1%) had CrCl <60 mL/min. The mean CHA2DS2-VASc and HAS-BLED were 3.5±1.5 and 1.6±1.0, respectively. During the follow-up, 7 (1.4%) patients with CrCl <60 mL/min suffered a thromboembolic event, 16 (3.2%) suffered major bleeding, and 19 (3.8%) suffered a MACE. Compared to patients with normal renal function, patients with CrCl <60 mL/min showed a higher annual rate of major bleeding (0.62%/year vs. 1.87%/year; p=0.003) and MACE (0.62%/year vs. 1.97%/year; p=0.002). Multivariate analyses demonstrated that the CHA2DS2-VASc score (OR 1.84; 95% CI 1.11–3.07) was associated with a higher risk of thromboembolic events; whereas the HAS-BLED score (OR 2.25; 95% CI 1.41–3.59) and any dependency level (OR 3.42; 95% CI 1.17–9.98) were associated with a higher risk of major bleeding; and male sex (OR 3.55; 95% CI 1.08–11.63) and heart failure (OR 4.67; 95% CI 1.62–13.51) with a higher risk of MACE. The use of antiplatelet agents was also independently associated with an increased risk of thromboembolic events and MACE (OR 12.28; 95% CI 2.50–60.18; and OR 8.72; 95% CI 2.86–26.59; respectively).

Conclusions

Rivaroxaban showed excellent results in moderate renal impairment. However, the annual rate of major bleeding and MACE was higher in AF patients with impaired renal function. In patients with AF and renal impairment, male sex, the presence of heart failure, dependency, the concomitant use of antiplatelets, and greater comorbidity according to the CHA2DS2-VASc and HAS-BLED, were associated with higher risk of adverse clinical outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bayer

Oral anticoagulation therapy with rivaroxaban in elderly patients with atrial fibrillation. Results from EMIR study

Background

Atrial fibrillation (AF) in elderly patients increases both bleeding and thromboembolic risks. Elderly patients benefit as much from anticoagulation therapy with positive net clinical benefit. However, there have been few studies that focused on the efficacy and safety of direct oral anticoagulants in elderly patients.

The aim of this subanalysis from EMIR study was to assess the effectiveness of rivaroxaban in patients older than 75 years old.

Methods

EMIR Study (acronym from 'Estudio observacional para la identificaciόn de los factores de riesgo asociados a eventos cardiovasculares Mayores en pacientes con fIbrilaciόn auricular no valvular tratados con un anticoagulante oral directo (Rivaroxaban)') was an observational, multicenter, post-authorization and prospective study that involved AF patients under oral anticoagulation with rivaroxaban at least 6 months before enrolment. We analyzed baseline clinical characteristics and adverse events after 2.5 years of follow up.

Results

We analyzed 1,433 patients with median age of 74.7 (67.7–81.6). Of them 691 (48.2%) were ≥75 years. Elderly patients had higher prevalence of cardiovascular risk factors such previous stroke (16.8% vs 8.5%; p<0.001), heart failure (25.0% vs 20.6%; p<0.001), higher CHA2DS2-VASc (4.4±1.3 vs 2.7±1.2; p<0.001) and HAS-BLED (1.9±1.0 vs 1.2±1.0; p<0.001) scores. After 2.5 (2.2–2.6) years of follow-up, we observed low rate of adverse events in patients under rivaroxaban therapy. We observed higher rate of adverse events in elderly population for thromboembolic events (1.13%/year vs 0.36%/year; p=0.017) and major bleeding events (1.80%/year vs 0.36%/year; p<0.001) but those adverse rates were lower than expected according to previous studies (i.e. ROCKET-AF trial, rivaroxaban group had 4.86%/year of major bleeding or in XANTUS study was 3.2%/year of major bleeding in patients >75 years). We did not observe differences between groups from MACE (1.13%/year vs 1.01%/year; p=0.875) or cardiovascular death (0.86%/year vs 0.42%/year; p=0.170).

Conclusion

In real-world elderly population, rivaroxaban showed higher rates of thromboembolic and major bleeding events in elderly patients but with annual rates lower than expected according to previous studies like ROCKET-AF or XANTUS. Similar annual rates in elderly were observed for MACE and cardiovascular mortality than in younger patients, being rivaroxaban a good therapeutic alternative even for the elderly.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer Hispania S.L.

Incidence of cardiovascular events in patients with atrial fibrillation anticoagulated with rivaroxaban after 2.5 years of follow-up: not all is stroke or bleeding

Introduction

Atrial fibrillation (AF) is not a benign arrhythmia, but is associated with an increase in mortality, above all related to the risk of suffering thromboembolic events, mainly stroke. The use of oral anticoagulants (OAC) reduces this risk, but increases the risk of serious bleeding. The DOACs have been shown to be superior to the classic vitamin K antagonists (VKAs). It is not as well known whether AF is associated with an increase in other serious cardiac events.

Purpose

The objective of this analysis was to assess the incidence of stroke, major bleeding, total mortality and major adverse cardiac events [MACE, defined as cardiac mortality (including death for coronary events, progressive heart failure death and sudden cardiac death), coronary revascularization, myocardial infarction] in a contemporary series of patients with AF anticoagulated with rivaroxaban.

Methods

To do this, we have analyzed a series of 1,433 patients with AF, anticoagulated with rivaroxaban for at least the previous 6 months, consecutively included in the first half of year 2017 in 79 Spanish centers (EMIR study), and followed for 2.5 years.

Results

Mean age was 74.2±9.7 years, 44.5% being women. Prevalence of diabetes was 27.1%, chronic renal failure 16.1%, coronary heart disease 16.4% and heart failure 22.7%. 2MACE score was 1.8±1.4, CHA2DS2-VASc was 3.5±1.5 and HAS-BLED 1.6±1.0. 77.1% of patients received 20 mg/ day of rivaroxaban and 22.9% 15 mg/day. After a follow-up of 2.5 years, the annual rate (events/100 patients/year) of myocardial infarction was 0.16 (all non-STEMI), coronary revascularization 0.28, cardiac death 0.63 (sudden 0.16, heart failure 0.41, other 0.06), overall MACE 1.07 and overall mortality 2.73, while the incidence of stroke was 0.57 / 100 patients / year (ischemic 0.35, haemorrhagic 0.22) and major bleeding 1.04 (gastrointestinal 0.63, intracranial 0.28).

Conclusion

In a current series of patients with AF anticoagulated with rivaroxaban, the incidence of embolic and hemorrhagic complications and mortality are low, while the incidence of serious cardiac events is significant, being overall similar to that of stroke and major bleeding. Attention must be paid to the prevention and diagnosis of these problems.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer Hispania