• Benjamin A Steinberg, Anne S Hellkamp, Yuliya Lokhnygina, Manesh R Patel, Günter Breithardt, Graeme J Hankey, Richard C Becker, Daniel E Singer, Jonathan L Halperin, Werner Hacke, Christopher C Nessel, Scott D Berkowitz, Kenneth W Mahaffey, Keith A A Fox, Robert M Califf, Jonathan P Piccini, and ROCKET-AF Steering Committee and Investigators.
• Duke Clinical Research Institute, PO Box 17969, NC 27715 Durham, NC, USA benjamin.steinberg@duke.edu.
• Eur. Heart J. 2015 Feb 1; 36 (5): 288-96.

AimAnticoagulation prophylaxis for stroke is recommended for at-risk patients with either persistent or paroxysmal atrial fibrillation (AF). We compared outcomes in patients with persistent vs. paroxysmal AF receiving oral anticoagulation.Methods And ResultsPatients randomized 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 (ROCKET-AF) trial (n = 14 264) were grouped by baseline AF category: paroxysmal or persistent. Multivariable adjustment was performed to compare thrombo-embolic events, bleeding, and death between groups, in high-risk subgroups, and across treatment assignment (rivaroxaban or warfarin). Of 14 062 patients, 11 548 (82%) had persistent AF and 2514 (18%) had paroxysmal AF. Patients with persistent AF were marginally older (73 vs. 72, P = 0.03), less likely female (39 vs. 45%, P < 0.0001), and more likely to have previously used vitamin K antagonists (64 vs. 56%, P < 0.0001) compared with patients with paroxysmal AF. In patients randomized to warfarin, time in therapeutic range was similar (58 vs. 57%, P = 0.94). Patients with persistent AF had higher adjusted rates of stroke or systemic embolism (2.18 vs. 1.73 events per 100-patient-years, P = 0.048) and all-cause mortality (4.78 vs. 3.52, P = 0.006). Rates of major bleeding were similar (3.55 vs. 3.31, P = 0.77). Rates of stroke or systemic embolism in both types of AF did not differ by treatment assignment (rivaroxaban vs. warfarin, Pinteraction = 0.6).ConclusionIn patients with AF at moderate-to-high risk of stroke receiving anticoagulation, those with persistent AF have a higher risk of thrombo-embolic events and worse survival compared with paroxysmal AF.© The Author 2014. Published by Oxford University Press on behalf of the European Society of Cardiology.

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