Atrial fibrillation and prior MI: searching for balance in ischaemic and bleeding events in patients treated with factor-specific anticoagulants

Abstract

This editorial refers to ‘Ischaemic cardiac outcomes in patients with atrial fibrillation treated with vitamin K antagonism or factor Xa inhibition: results from the ROCKET AF trial’, by K.W. Mahaffey et al. doi:10.1093/eurheartj/eht428 Patients with both atrial fibrillation (AF) and prior myocardial infarction (MI) represent a unique and potentially high risk population. Strategies for managing these patients using the newer factor-specific oral anticoagulants are somewhat limited, as these patients represent a small fraction of the overall cohorts studied and only limited results have been published previously.1,2 Mahaffey et al. , investigators from the ROCKET AF (Rivaroxaban Once-daily, oral, direct Factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) trial,3 now report on the prevalence of prior MI in that study; the incidence of new cardiovascular (CV) events; and the treatment effect of rivaroxaban, a direct factor Xa inhibitor, compared with warfarin on the risk of new CV events in those with and without a history of MI. In the ROCKET AF trial, 17% of patients had prior MI at enrolment ( n = 2468/14 264).3 These subjects were significantly more likely to have other co-morbidities and risk factors, notably more heart failure, diabetes, and peripheral arterial disease. Additionally, concomitant aspirin (47% vs. 34%) and thienopyridine (3.4% and 2.1%) were more common in this subgroup. Patients with and without prior MI had similar rates of stroke and systemic embolism during a median 2 years of follow-up, but recurrent CV events and mortality were more frequent …