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26
VOLUME 9 NUMBER 1 • MARCH 2012
EVIDENCE IN PRACTICE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
A
pixaban, an oral direct factor Xa inhibitor, significantly
reduced stroke and systemic embolism compared to
warfarin in patients with atrial fibrillation (AF) and at least
one risk factor for stroke, according to results from a major
study.
The Apixaban for Reduction in Stroke and Other
Thromboembolic Events in Atrial Fibrillation (ARISTOTLE)
trial randomised 18 201 patients with AF and at least one
additional risk factor for stroke to apixaban (5 mg twice daily;
2.5 mg in selected patients) or warfarin (dosed to achieve a
target INR of 2.0–3.0).
Results, reported during a hot-line session at European
Society of Cardiology and published in the
New England
Journal ofMedicine
, showed that apixaban reduced the relative
risk of stroke or systolic embolism by 21% (
p
= 0.01) and all-
cause mortality by 11% (
p
= 0.047). The predominant effect
on stroke prevention was on haemorrhagic stroke, which was
49% lower with apixaban than warfarin (
p
< 0.001), along
with an effect on ischaemic or uncertain stroke that was 8%
lower with apixaban than with warfarin (
p
= 0.42, NS).
Apixaban was superior to warfarin for the primary safety
outcome of major bleeding, which was reduced by 31%
compared to warfarin (
p
< 0.001). Major or clinically relevant
non-major bleeding was reduced by 32% (
p
< 0.001).
‘These are important findings because they show when
compared to warfarin, itself a very effective treatment to
prevent stroke, apixaban resulted in an additional 21%
relative reduction in stroke and systemic embolism,’ said lead
investigator Christopher Granger, Professor of Medicine at Duke
University, Durham, USA. ‘There is an enormous unmet need in
terms of treatment of patients at risk of stroke associated with
atrial fibrillation,’ says Professor Granger. ‘Only about half of
patients who should be treated are being treated. The disparity
exists because warfarin treatment has several limitations.’
Adverse events were similar in the apixaban (81.5%) and
warfarin (83.1%) groups, aswere serious adverse events (35.0%
with apixaban and 36.5% with warfarin). Discontinuation
of study drug was significantly less common with apixaban
(25.3% of patients, 3.6% due to death) than with warfarin
(27.5% of patients, 3.8% due to death;
p
= 0.001).
Originally from
PCCJ
2011;
4
(4): 141.
Apixaban is superior to warfarin
in reducing stroke or systemic
embolism in atrial fibrillation
SAJDVD recommended action
Apixaban is not yet licensed for stroke prevention in patients with
AF in South Africa, but this study shows that the oral agent is more
effective than warfarin without the need for anticoagulation
monitoring. It is also safer, with a substantially lower risk of all
types of bleeding and lower rates of discontinuation.
Reference
Granger CB, Alexander JH, McMurray JJV,
et al.
Apixaban versus
warfarin in patients with atrial fibrillation.
N Engl J Med
2011 Aug
28; doi 10.1056/NEJMoa1107039. ESC 2011. Hot Line 1.
http://www.escardio.org/congresses/esc-2011/congressreports/
Pages/706-4-ARISTOTLE.aspx
A
mbulatory blood pressure monitoring (ABPM) is the most cost-
effective way to diagnose hypertension. Studies have shown
that the average blood pressure over 24 hours is a better predictor of
long-term cardiovascular outcome than blood pressure (BP) measured
during a standard clinic appointment. About one person in four with a
raised reading in clinic will not have a raised ambulatory recording.
Thenewstudycomparedthecost-effectivenessofBPmeasurements
in the clinic, home and over 24 hours. The researchers found that
ambulatory monitoring was the most cost-effective strategy in men
and women of all ages.
Diagnosis using ambulatory readings after an initially high clinic
reading confirms genuine cases of hypertension, and prevents treat-
ment of patients whose ambulatory readings suggest their BP is
normal.
The authors concluded that ambulatory monitoring improves
health, increases quality of life, and reduces costs and that ambulatory
monitoring should be seriously considered for most people before
the start of antihypertensive treatment. Senior author of the analysis,
Professor Richard McManus (University of Birmingham) said:
‘Ambulatory monitoring allows better targeting of BP treatment to
those who will receive most benefit. It is already undertaken in some
general practices and while implementation on a wide scale will need
to be phased in to allow training and acquisition of new equipment,
it is cost saving in the long term as well as more effective and so will
be good for patients and doctors alike.’
Originally from
PCCJ
2011;
4
(4): 141.
SAJDVD recommended action
Ambulatory BP measurement is now the recommended approach in assessing
people with hypertension. Primary care practices should take active steps to
introduce this approach into their practice.
Reference
Lovibond K, Jowett S, Barton P,
et al
. Cost-effectiveness of options for the
diagnosis of high blood pressure in primary care: a modelling study.
Lancet
2011; DOI:10.1016/S0140-6736(11)61184-7
Ambulatory BP measurement:
most cost-effective way to
diagnose hypertension