Use and outcomes of antiarrhythmic therapy in patients with atrial fibrillation receiving oral anticoagulation: results from the ROCKET AF trial.

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

Journal: Heart rhythm 2015;11(6):925-32

PMID: 24833235

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Abstract

BACKGROUND

Antiarrhythmic drugs (AADs) and anticoagulation are mainstays of atrial fibrillation (AF) treatment.

OBJECTIVE

To study the use and outcomes of AAD therapy in anticoagulated patients with AF.

METHODS

Patients 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 trial (N = 14,264) were stratified by AAD use at baseline: amiodarone, other AAD, or no AAD. Multivariable adjustment was performed to compare stroke, bleeding, and death across AAD groups as well as across treatment assignment (rivaroxaban or warfarin).

RESULTS

Of 14,264 patients randomized, 1681 (11.8%) were treated with an AAD (1144 [8%] with amiodarone and 537 [3.8%] with other AADs). Amiodarone-treated patients were less often female (38% vs 48%), had more persistent AF (64% vs 40%), and more concomitant heart failure (71% vs 41%) than were patients receiving other AADs. Patients receiving no AAD more closely resembled amiodarone-treated patients. Time in therapeutic range was significantly lower in warfarin-treated patients receiving amiodarone than in those receiving no AAD (50% vs 58%; P < .0001). Compared with no AAD, neither amiodarone (adjusted hazard ratio [HR] 0.98; 95% confidence interval [CI] 0.74-1.31; P = .9) nor other AADs (adjusted HR 0.66; 95% CI 0.37-1.17; P = .15) were associated with increased mortality. Similar results were observed for embolic and bleeding outcomes. Treatment effects of rivaroxaban vs warfarin in patients receiving no AAD were consistent with results from the overall trial (primary end point: adjusted HR 0.82; 95% CI 0.68-0.98; Pinteraction = .06; safety end point: adjusted HR 1.12; 95% CI 0.90-1.24; Pinteraction = .33).

CONCLUSION

Treatment with AADs was not associated with increased morbidity or mortality in anticoagulated patients with AF. The effect of amiodarone on outcomes in patients receiving rivaroxaban requires further investigation.

Address: Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina. Electronic address: [email protected].; Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.; Cardiovascular Institute, Mount Sinai Medical Center, New York, New York.; Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany.; Northwestern University Feinberg School of Medicine, Chicago, Illinois.; School of Medicine and Pharmacology, The University of Western Australia, Crawley, Australia.; University of Cincinnati College of Medicine, Cincinnati, Ohio.; Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.; Ruprecht-Karls-University, Heidelberg, Germany.; Bayer HealthCare Pharmaceuticals, Montville, New Jersey.; Janssen Research & Development LLC, Raritan, New Jersey.; Department of Medicine, Stanford University, Stanford, California.; University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.; Duke Translational Medicine Institute, Duke University Medical Center, Durham, North Carolina.

DOI: 10.1016/j.hrthm.2014.03.006

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MeSH Terms: Aged, Amiodarone, Anti-Arrhythmia Agents, Anticoagulants, Atrial Fibrillation, Female, Humans, Intention to Treat Analysis, Male, Middle Aged, Morpholines, Rivaroxaban, Thiophenes, Treatment Outcome