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

ROCKET-AF Steering Committee and Investigators, Benjamin A Steinberg, Anne S Hellkamp, Yuliya Lokhnygina, Manesh R Patel, Günter Breithardt, Graeme J Hankey, Richard C Becker, Daniel E Singer, Jonathan L Halperin, Werner Hacke, Christopher C Nessel, Scott D Berkowitz, Kenneth W Mahaffey, Keith A A Fox, Robert M Califf, Jonathan P Piccini

Research output: Contribution to journalArticlepeer-review

Abstract / Description of output

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.

Original languageEnglish
Pages (from-to)288-96
Number of pages9
JournalEuropean Heart Journal
Issue number5
Publication statusPublished - 1 Feb 2015

Keywords / Materials (for Non-textual outputs)

  • Administration, Oral
  • Aged
  • Anticoagulants
  • Atrial Fibrillation
  • Cause of Death
  • Double-Blind Method
  • Drug Administration Schedule
  • Factor Xa Inhibitors
  • Female
  • Follow-Up Studies
  • Humans
  • Kaplan-Meier Estimate
  • Male
  • Morpholines
  • Prospective Studies
  • Risk Factors
  • Stroke
  • Thiophenes
  • Treatment Outcome
  • Vitamin K
  • Warfarin


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