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Randomized Controlled Trial
. 2015 Feb 1;36(5):288-96.
doi: 10.1093/eurheartj/ehu359. Epub 2014 Sep 10.

Higher risk of death and stroke in patients with persistent vs. paroxysmal atrial fibrillation: results from the ROCKET-AF Trial

Benjamin A Steinberg  1 , Anne S Hellkamp  2 , Yuliya Lokhnygina  2 , Manesh R Patel  2 , Günter Breithardt  3 , Graeme J Hankey  4 , Richard C Becker  5 , Daniel E Singer  6 , Jonathan L Halperin  7 , Werner Hacke  8 , Christopher C Nessel  9 , Scott D Berkowitz  10 , Kenneth W Mahaffey  11 , Keith A A Fox  12 , Robert M Califf  13 , Jonathan P Piccini  2 ; ROCKET-AF Steering Committee and Investigators
Affiliations
Randomized Controlled Trial

Higher risk of death and stroke in patients with persistent vs. paroxysmal atrial fibrillation: results from the ROCKET-AF Trial

Benjamin A Steinberg et al. Eur Heart J. .

Abstract

Aim: Anticoagulation prophylaxis for stroke is recommended for at-risk patients with either persistent or paroxysmal atrial fibrillation (AF). We compared outcomes in patients with persistent vs. paroxysmal AF receiving oral anticoagulation.

Methods and results: Patients randomized in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET-AF) trial (n = 14 264) were grouped by baseline AF category: paroxysmal or persistent. Multivariable adjustment was performed to compare thrombo-embolic events, bleeding, and death between groups, in high-risk subgroups, and across treatment assignment (rivaroxaban or warfarin). Of 14 062 patients, 11 548 (82%) had persistent AF and 2514 (18%) had paroxysmal AF. Patients with persistent AF were marginally older (73 vs. 72, P = 0.03), less likely female (39 vs. 45%, P < 0.0001), and more likely to have previously used vitamin K antagonists (64 vs. 56%, P < 0.0001) compared with patients with paroxysmal AF. In patients randomized to warfarin, time in therapeutic range was similar (58 vs. 57%, P = 0.94). Patients with persistent AF had higher adjusted rates of stroke or systemic embolism (2.18 vs. 1.73 events per 100-patient-years, P = 0.048) and all-cause mortality (4.78 vs. 3.52, P = 0.006). Rates of major bleeding were similar (3.55 vs. 3.31, P = 0.77). Rates of stroke or systemic embolism in both types of AF did not differ by treatment assignment (rivaroxaban vs. warfarin, Pinteraction = 0.6).

Conclusion: In patients with AF at moderate-to-high risk of stroke receiving anticoagulation, those with persistent AF have a higher risk of thrombo-embolic events and worse survival compared with paroxysmal AF.

Keywords: Anticoagulation; Atrial fibrillation; Outcomes; Paroxysmal; Persistent.

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Figures

Figure 1
Figure 1
Unadjusted Kaplan–Meier event curves for all-cause mortality, by atrial fibrillation type at baseline. AF, atrial fibrillation, HR, hazard ratio; CI, confidence interval.
Figure 2
Figure 2
Forest plot of the composite end-point of stroke, systemic embolism, or death for paroxysmal vs. persistent atrial fibrillation, stratified by high-risk subgroups. All strata assessed at baseline. AF, atrial fibrillation; AFL, atrial flutter; CHF, congestive heart failure; CKD, chronic kidney disease; ECG, electrocardiogram; SE, systemic embolism.
Figure 3
Figure 3
Unadjusted Kaplan–Meier event curves for stroke or systemic embolism, by atrial fibrillation type and treatment assignment. AF, atrial fibrillation; HR, hazard ratio, CI, confidence interval.
See this image and copyright information in PMC

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