Last updated on April 2018

Apixaban for the Reduction of Thrombo-Embolism in Patients With Device-Detected Sub-Clinical Atrial Fibrillation


Brief description of study

This study aims to determine if treatment with apixaban, compared with aspirin, will reduce the risk of ischemic stroke and systemic embolism in patients with device-detected sub-clinical atrial fibrillation and additional risk factors for stroke.

Detailed Study Description

Device-detected sub-clinical atrial fibrillation (SCAF) is a new disorder that has been recognized since the availability of implantable devices capable of long term continuous heart rhythm monitoring. It is characterized by one or more runs of rapid atrial arrhythmia detected by the device without symptoms and without any clinical atrial fibrillation (AF) detected by the usual methods, (i.e. electrocardiogram, Holter monitor, etc.). In the ASSERT trial, SCAF was detected by a pacemaker or implantable cardioverter defibrillator (ICD) in nearly 40% of patients during 2 and a half years of follow up. The presence of SCAF increased stroke risk by 2.5-fold (1). The risk of stroke or systemic embolism among patients with SCAF and a CHADS2 score 4 was 2.75% per year. Oral anticoagulation is effective and safe for stroke prevention in patients with clinical atrial fibrillation, but it is unknown if the same risk benefit ratio exists for anticoagulation therapy in patients with SCAF (2;3). SCAF differs from clinical AF in being of shorter duration, being asymptomatic, and often have a more regular rhythm in the right atrium where it is typically detected. Data ASSERT suggest that the increase in stroke risk with SCAF may be less than the increase with clinical AF. Therefore opinion leaders have written that the role of oral anticoagulation for the treatment of SCAF is uncertain and that randomized trials of anticoagulation are needed (4;5). Recent surveys of pacemaker clinic practice indicate that only 25% of patients with SCAF are treated with oral anticoagulation (6;7). Thus there is clinical equipoise for a trial of oral anticoagulation compared to aspirin in higher risk patients with SCAF.

Apixaban is a Factor Xa inhibitor that is an effective and safe anticoagulant. It has been shown to have an excellent risk benefit profile for stroke prevention in clinical AF (14, 15). It is highly suitable to test if oral anticoagulation therapy will reduce the risk of stroke or systemic embolism in SCAF.

Patients will be randomized double-blind to receive apixaban or aspirin. Apixaban dose will be 5 mg twice daily (2.5 mg twice daily if 2 or more of: age > 80, weight 60 kg or serum creatinine 133 mmol/L). Those assigned to aspirin will receive a dose of 81 mg daily. The study will be event driven and will continue until 248 patients have experienced a primary outcome event.

Clinical Study Identifier: NCT01938248

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St. Vincent Heart Clinic

Little Rock, AR United States
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Glacier View Cardiology

Kalispell, MT United States
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Carolinas Healthcare System

Charlotte, NC United States
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WakeMed

Raleigh, NC United States
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Cleveland Clinic

Cleveland, OH United States
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AZ Groeninge

Kortrijk, Belgium
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AZ Delta

Roeselare, Belgium
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CHUM - Hotel Dieu

Montreal, QC Canada
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CHUS - Sherbrooke

Sherbrooke, QC Canada
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Ziekenhuis Tjongerschans

Heerenveen, Netherlands
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Gelre Ziekenhuis

Zutphen, Netherlands
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Ikazia Ziekenhuis

Rotterdam, Netherlands
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BovenIJ Ziekenhuis

Amsterdam, Netherlands
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Hospital Rijnstate

Arnhem, Netherlands
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M xima Medisch Centrum

Veldhoven, Netherlands
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Freeman Hospital

Newcastle-upon-Tyne, United Kingdom
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Tufts Medical Center

Boston, MA United States
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Michigan Heart

Ypsilanti, MI United States
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St. Louis Heart and Vascular

Saint Louis, MO United States
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The Cooper Health System

Camden, NJ United States
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The Valley Hospital

Ridgewood, NJ United States
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Virginia Heart

Falls Church, VA United States
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Grey Nuns Hospital

Edmonton, AB Canada
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Ospedale Sant'Anna

San fermo della Batt, Italy
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CHUV

Lausanne, Switzerland
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Kantonsspital St Gallen

St. Gallen, Switzerland
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Royal Alexandra Hospital

Paisley, United Kingdom
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Ciusss McQ

Trois-Rivières, QC Canada
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Ospedale Sant'Anna

San Fermo Della Batt, Italy
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Recruitment Status: Open


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