News | Heart Failure | September 07, 2018

Antithrombin Drug Ineffective in Heart Failure With Sinus Rhythm and Coronary Disease

Rivaroxaban does not lower rates of all-cause mortality, myocardial infarction or stroke

Antithrombin Drug Ineffective in Heart Failure With Sinus Rhythm and Coronary Disease

September 7, 2018 — The antithrombin drug rivaroxaban does not reduce the risk of a composite endpoint of survival, myocardial infarction and stroke after an episode of worsening heart failure in patients with heart failure, sinus rhythm and coronary artery disease. These conclusions came from late-breaking results from the COMMANDER HF trial presented in a Hot Line Session at the European Society of Cardiology (ESC) Congress 2018, Aug. 25-28 in Munich, Germany, and with simultaneous publication in the New England Journal of Medicine.1

After an episode of worsening heart failure, patients experience high rates of hospital readmission and death, particularly in the first few months. Previous studies have suggested that the enzyme thrombin may contribute to these poor outcomes by inducing inflammation, endothelial dysfunction and clot formation (thrombosis) in blood vessels.2

Rivaroxaban is an oral, direct factor Xa inhibitor that reduces thrombin generation. Higher doses (10–20 mg daily) are approved to treat and prevent venous thromboembolism, and prevent stroke or systemic embolism in patients with atrial fibrillation. Lower doses (2.5 mg twice daily), combined with antiplatelets, reduce cardiovascular mortality, myocardial infarction, and stroke in patients with acute coronary syndromes or stable coronary artery disease.

The COMMANDER HF trial tested whether, compared to placebo, rivaroxaban 2.5 mg twice daily could reduce thrombin generation and thereby lower rates of death and cardiovascular events in patients with recent worsening of chronic heart failure, who had reduced ejection fraction (40 percent or less), coronary artery disease and no atrial fibrillation.

Prof. Faiez Zannad, study author, University of Lorraine, Nancy, France, said, “COMMANDER HF is not just another trial of oral anticoagulation in heart failure. The aim is to interfere with disease processes that rely on thrombin using a targeted antithrombin drug.”

The trial enrolled 5,022 patients from 628 sites in 28 countries. Patients were randomly assigned to rivaroxaban 2.5 mg, taken orally twice daily, or matching placebo. The use of guideline recommended therapies for heart failure and coronary artery disease was well balanced between groups and included diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists. Background therapy included aspirin in virtually all patients, and a substantial number were also receiving dual antiplatelet agents at the time either rivaroxaban or placebo was initiated in the trial.

The median age of participants at the start of the study was 66 years, 23 percent were women and the median ejection fraction was 34 percent. Patients were followed-up for the primary efficacy outcome of all-cause mortality, myocardial infarction or stroke. The primary safety outcome was the composite of fatal bleeding or bleeding into a critical space with a potential for permanent disability.

During a median follow-up of 21.1 months, the primary efficacy outcome occurred in 626 (25 percent) of 2,507 patients assigned to rivaroxaban compared to 658 (26.2 percent) of 2,515 on placebo (hazard ratio [HR] 0.94, 95 percent confidence interval [CI] 0.84–1.05, p=0.27). There were no differences between groups in all-cause mortality (HR 0.98, 95 percent CI 0.87–1.10, p=0.74) or nonfatal myocardial infarction (HR 0.83, 95 percent CI 0.63–1.08, p=0.17) but there was a significantly lower rate of nonfatal stroke in the rivaroxaban, compared to placebo, group (HR 0.66, 95 percent CI 0.47–0.95, p=0.023).

The principal safety outcome occurred in 18 (0.7 percent) patients assigned to rivaroxaban and 23 (0.9 percent) assigned to placebo (HR 0.80, 95 percent CI 0.43–1.49, p=0.48). Patients taking rivaroxaban had a significantly higher risk of major bleeding as defined by the International Society on Thrombosis and Haemostasis (ISTH) compared to those on placebo (HR 1.68, 95 percent CI 1.18–2.39, p=0.003). This result was mainly driven by the ISTH criterion of bleeding causing a fall in haemoglobin of 2 g/dL (1.24 mmol/L) or more.

Serious adverse events were reported in 479 (19.2 percent) patients taking rivaroxaban and 451 (18 percent) on placebo. The percentage of patients who permanently discontinued study medication due to an adverse event was 7.1 percent in the rivaroxaban group and 5.8 percent in the placebo group.

Zannad said, “The most likely reason rivaroxaban failed to improve the primary efficacy outcome is that thrombin-mediated events are not the major driver of cardiovascular events in patients with recent heart failure hospitalization. Whether a higher dose of rivaroxaban could have led to a more favorable result is unknown.”

For more information: www.nejm.org

Reference

1. Zannad F., Anker S.D., Byra W.M., et al. Rivaroxaban in Patients with Heart Failure, Sinus Rhythm, and Coronary Disease. New England Journal of Medicine, Aug. 27, 2018. DOI: 10.1056/NEJMoa1808848

2. Zannad F., Greenberg B., Cleland J.G., et al. Rationale and design of a randomized, double-blind, event-driven, multicentre study comparing the efficacy and safety of oral rivaroxaban with placebo for reducing the risk of death, myocardial infarction or stroke in subjects with heart failure and significant coronary artery disease following an exacerbation of heart failure: the COMMANDER HF trial. Europ J Heart Fail. 2015;17:735–742. doi: 10.1002/ejhf.266.

Related Content

Experimental Vaccine May Reduce Post-Stroke Blood Clot Risk
News | Antiplatelet and Anticoagulation Therapies | November 01, 2018
A vaccine may one day be able to replace oral blood thinners to reduce the risk of secondary strokes caused by blood...
Thrombolytic Science Initiates Phase 2 Trial of Novel Ischemic Stroke Treatment Regimen
News | Antiplatelet and Anticoagulation Therapies | September 07, 2018
A new Phase 2 clinical trial looks to confirm the efficacy and safety of Thrombolytic Science LLC’s (TSI) sequential...
Bleeds and Benefit With Aspirin Balanced in Diabetes Patients
News | Antiplatelet and Anticoagulation Therapies | September 05, 2018
Aspirin prevented serious vascular events in patients with diabetes who did not already have cardiovascular disease,...
Extended Post-Hospital Oral Anticoagulant Use Reduces Non-Fatal Blood Clots
News | Antiplatelet and Anticoagulation Therapies | August 31, 2018
Use of an oral anticoagulant in medically ill patients for 45 days following hospital discharge reduces the rate of non...
AFib Patients Want More Information About Anticoagulation Reversal
News | Antiplatelet and Anticoagulation Therapies | June 27, 2018
Results from a 902-person, five-country survey of people living with atrial fibrillation (AF) reinforce the importance...
Lower Oral DOAC Anticoagulant Use Associated With More Thromboembolic Events Than Warfarin. #HRS 2018
News | Antiplatelet and Anticoagulation Therapies | May 18, 2018
May 18, 2018 — Nearly half of patients prescribed warfarin and just under one third of those using newer direct oral
The U.S. Food and Drug Administration (FDA) has approved Portola Pharmaceuticals' Andexxa, the first antidote indicated for patients treated with rivaroxaban (Xarelto) and apixaban (Eliquis), when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding.

The U.S. Food and Drug Administration (FDA) has approved Portola Pharmaceuticals' Andexxa, the first antidote indicated for patients treated with rivaroxaban (Xarelto) and apixaban (Eliquis), when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding.

 

Feature | Antiplatelet and Anticoagulation Therapies | May 07, 2018
The U.S. Food and Drug Administration (FDA) has approved Portola Pharmaceuticals' Andexxa, the first antidote indicated...
The largest trial to date for short-term DAPT concluded the practice cannot be deemed safe due to a higher adverse event rate. Image courtesy of the American Heart Association. #ACC18

The largest trial to date for short-term DAPT concluded the practice cannot be deemed safe due to a higher adverse event rate. Image courtesy of the American Heart Association.

News | Antiplatelet and Anticoagulation Therapies | March 19, 2018
The combined rate of death from any cause, heart attack or stroke within 18 months was not significantly different in...
The Xarelto booth at ACC.18

The Xarelto booth at the 2018 American College of Cardiology meeting. 

News | Antiplatelet and Anticoagulation Therapies | March 14, 2018
March 14, 2018 — A late-breaking analysis of the landmark COMPASS study presented at the American College of Cardiolo
Overlay Init