Michael T Durheim1, Derek D Cyr2, Renato D Lopes3, Laine E Thomas2, Wayne M Tsuang4, Bernard J Gersh5, Claes Held6, Lars Wallentin6, Christopher B Granger3, Scott M Palmer7, Sana M Al-Khatib3. 1. Duke Clinical Research Institute, Durham, NC, USA; Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA. Electronic address: michael.durheim@duke.edu. 2. Duke Clinical Research Institute, Durham, NC, USA. 3. Duke Clinical Research Institute, Durham, NC, USA; Division of Cardiology, Duke University Medical Center, Durham, NC, USA. 4. Department of Pulmonary Medicine, Cleveland Clinic, Cleveland, OH, USA. 5. Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN, USA. 6. Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden. 7. Duke Clinical Research Institute, Durham, NC, USA; Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, NC, USA.
Abstract
BACKGROUND:Comorbid chronic obstructive pulmonary disease (COPD) is associated with poor outcomes among patients with cardiovascular disease. The risks of stroke and mortality associated with COPD among patients with atrial fibrillation are not well understood. METHODS: We analyzed patients from ARISTOTLE, a randomized trial of 18,201 patients with atrial fibrillation comparing the effects of apixaban versus warfarin on the risk of stroke or systemic embolism. Using Cox proportional hazards models, we assessed the associations between comorbid COPD and risk of stroke or systemic embolism and of mortality, adjusting for treatment allocation, smoking history and other risk factors. RESULTS:COPD was present in 1950 (10.8%) of 18,134 patients with data on pulmonary disease history. After multivariable adjustment, COPD was not associated with risk of stroke or systemic embolism (adjusted HR 0.85 [95% CI 0.60, 1.21], p=0.356). However, COPD was associated with a higher risk of all-cause mortality (adjusted HR 1.60 [95% CI 1.36, 1.88], p<0.001) and both cardiovascular and non-cardiovascular mortality. The benefit of apixaban over warfarin on stroke or systemic embolism was consistent among patients with and without COPD (HR 0.92 [95% CI 0.52, 1.63] versus 0.78 [95% CI 0.65, 0.95], interaction p=0.617). CONCLUSIONS:COPD was independently associated with increased risk of cardiovascular and non-cardiovascular mortality among patients with atrial fibrillation, but was not associated with risk of stroke or systemic embolism. The effect of apixaban on stroke or systemic embolism in COPD patients was consistent with its effect in the overall trial population.
RCT Entities:
BACKGROUND: Comorbid chronic obstructive pulmonary disease (COPD) is associated with poor outcomes among patients with cardiovascular disease. The risks of stroke and mortality associated with COPD among patients with atrial fibrillation are not well understood. METHODS: We analyzed patients from ARISTOTLE, a randomized trial of 18,201 patients with atrial fibrillation comparing the effects of apixaban versus warfarin on the risk of stroke or systemic embolism. Using Cox proportional hazards models, we assessed the associations between comorbid COPD and risk of stroke or systemic embolism and of mortality, adjusting for treatment allocation, smoking history and other risk factors. RESULTS:COPD was present in 1950 (10.8%) of 18,134 patients with data on pulmonary disease history. After multivariable adjustment, COPD was not associated with risk of stroke or systemic embolism (adjusted HR 0.85 [95% CI 0.60, 1.21], p=0.356). However, COPD was associated with a higher risk of all-cause mortality (adjusted HR 1.60 [95% CI 1.36, 1.88], p<0.001) and both cardiovascular and non-cardiovascular mortality. The benefit of apixaban over warfarin on stroke or systemic embolism was consistent among patients with and without COPD (HR 0.92 [95% CI 0.52, 1.63] versus 0.78 [95% CI 0.65, 0.95], interaction p=0.617). CONCLUSIONS:COPD was independently associated with increased risk of cardiovascular and non-cardiovascular mortality among patients with atrial fibrillation, but was not associated with risk of stroke or systemic embolism. The effect of apixaban on stroke or systemic embolism in COPDpatients was consistent with its effect in the overall trial population.
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Authors: Angela Lowenstern; Sana M Al-Khatib; Lauren Sharan; Ranee Chatterjee; Nancy M Allen LaPointe; Bimal Shah; Ethan D Borre; Giselle Raitz; Adam Goode; Roshini Yapa; J Kelly Davis; Kathryn Lallinger; Robyn Schmidt; Andrzej S Kosinski; Gillian D Sanders Journal: Ann Intern Med Date: 2018-10-30 Impact factor: 51.598