Rocketing into the future of AF

It feels like only yesterday that the ‘new’ age of anticoagulants was dawning on us – and this year has really brought their arrival. You might remember the EINSTEIN study, looking at the use of rivaroxaban in DVT, but the big use of warfarin is of course for embolic stroke prevention in AF – and here’s the landmark trial. 

Rivaroxaban, one of the new direct Xa inhibitors, has been looked at in AF before, in patients who couldn’t have warfarin, and it certainly fared better than aspirin. This trial however compared over 14,000 people, in a double blinded, double dummy, randomised controlled trial across 45 countries – wow. It was drug company sponsored however (but the trial was co-ordinated and primary analysis done without their fingers in the pie). 

The primary endpoint was composite – a combination of stroke (both ischaemic and haemorrhagic) and systemic embolism. Follow up was for almost 2 years, and only 32 patients were lost to follow up. 

Results? Well, for the primary endpoint, the hazard ratio was 0.79 – certainly demonstrating non-inferiority. Overall bleeding was 0.4% higher in the rivaroxaban group, but major bleeding was less (although transfusions were more frequently required in the rivaroxaban group…) – and in particular, GI bleeding was higher with the new anticoagulant. 

One of the points to note though is that the time in the therapeutic range in terms of INR for the warfarin group was about 55%, less than that in other studies – but then again, this just adds fuel to the new anticoagulant argument. 

This is definitely a defining study when the look back on the management of AF, and is definitely going to be part of the next guideline update. Read all about ROCKET-AF, over at NEJM, here

VIA The New England Journal of Medicine
IMAGE mtshaw


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