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Effectiveness and Safety of Anticoagulants in Adults with Non-valvular Atrial Fibrillation and Concomitant Coronary/Peripheral Artery Disease.
Am J Med. 2018 May 25;:
Authors: Lopes RD, Steffel J, Fusco MD, Keshishian A, Luo X, Li X, Masseria C, Hamilton M, Friend K, Gupta K, Mardekian J, Pan X, Baser O, Jones WS
Abstract
BACKGROUND: Direct oral anticoagulants (DOAC) are at least non-inferior to warfarin in efficacy and safety among non-valvular atrial fibrillation patients. Limited evidence is available regarding outcomes for non-valvular atrial fibrillation patients with coronary/peripheral artery disease.
METHODS: Non-valvular atrial fibrillation patients ≥65 years diagnosed with coronary/peripheral artery disease in the US Medicare population, newly initiating DOACs (apixaban, rivaroxaban, dabigatran) or warfarin were selected from 01JAN2013-31SEP2015. Propensity score matching was used to compare DOACs versus warfarin. Cox proportional hazards models were used to estimate the risk of stroke/systemic embolism, major bleeding, and composite of stroke/myocardial infarction/all-cause mortality.
RESULTS: 15,527 apixaban-warfarin, 6,962 dabigatran-warfarin, and 25,903 rivaroxaban-warfarin matched pairs, with a mean follow-up of 5-6 months, were identified. Compared to warfarin, apixaban was associated with lower rates of stroke/systemic embolism (hazard ratio (95% CI): 0.48 (0.37-0.62)), major bleeding (0.66 (0.58-0.75)) and stroke/myocardial infarction/all-cause mortality (0.63 (0.58-0.69)); dabigatran and rivaroxaban were associated with lower rates of stroke/myocardial infarction/all-cause mortality (0.79 (0.70-0.90); 0.87 (0.81-0.92), respectively). Rivaroxaban was associated with a lower rate of stroke/systemic embolism (0.72 (0.60-0.89)) and a higher rate of major bleeding (1.14(1.05-1.23)) versus warfarin.
CONCLUSIONS: All DOACs were associated with lower stroke/myocardial infarction/all-cause mortality rates compared to warfarin, differences were observed in rates of stroke/systemic embolism and major bleeding. Findings from this observational analysis provide important insights about oral anticoagulation therapy among non-valvular atrial fibrillation patients with coronary/peripheral artery disease and may help physicians in the decision-making process when treating this high-risk group of patients.
PMID: 29807001 [PubMed - as supplied by publisher]