Abstract
Background
Direct oral anticoagulants (DOAC) are at least non-inferior to warfarin in efficacy
and safety among patients with nonvalvular atrial fibrillation. Limited evidence is
available regarding outcomes for nonvalvular atrial fibrillation patients with coronary/peripheral
artery disease.
Methods
Non-valvular atrial fibrillation patients aged ≥65 years diagnosed with coronary/peripheral
artery disease in the US Medicare population, newly initiating DOACs (apixaban, rivaroxaban,
dabigatran) or warfarin were selected from January 1, 2013 to September 30, 2015.
Propensity score matching was used to compare DOACs vs 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
There were 15,527 apixaban-warfarin, 6,962 dabigatran-warfarin, and 25,903 rivaroxaban-warfarin–matched
pairs, with a mean follow-up of 5-6 months. Compared with warfarin, apixaban was associated
with lower rates of stroke/systemic embolism (hazard ratio [HR] 0.48; 95% confidence
interval [CI], 0.37-0.62), major bleeding (HR 0.66; 95% CI, 0.58-0.75), and stroke/myocardial
infarction/all-cause mortality (HR 0.63; 95% CI, 0.58-0.69); dabigatran and rivaroxaban
were associated with lower rates of stroke/myocardial infarction/all-cause mortality
(HR 0.79; 95% CI, 0.70-0.90 and HR 0.87; 95% CI, 0.81-0.92, respectively). Rivaroxaban
was associated with a lower rate of stroke/systemic embolism (HR 0.72; 95% CI, 0.60-0.89)
and a higher rate of major bleeding (HR 1.14; 95% CI, 1.05-1.23) vs warfarin.
Conclusions
All DOACs were associated with lower stroke/myocardial infarction/all-cause mortality
rates compared with 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.
Keywords
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Article info
Publication history
Published online: May 26, 2018
Accepted:
May 3,
2018
Received in revised form:
May 3,
2018
Received:
March 28,
2018
Footnotes
Funding: This study was funded by Pfizer Inc. and Bristol-Myers Squibb Company.
Conflict of Interest: RDL received research support from Bristol-Myers Squibb, GlaxoSmithKline, Medtronic, Pfizer and consulting fees from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, GlaxoSmithKline, Medtronic, Merck, Pfizer, Portola. X Li, MH, KG, KF, and XP are paid employees of Bristol-Myers Squibb, with ownership of stocks in Bristol-Myers Squibb Company. CM, X Luo, MDF, and JM are paid employees of Pfizer Inc., with ownership of stocks in Pfizer Inc. AK is a paid employee of STATinMED Research, which is a paid consultant to Pfizer and Bristol-Myers Squibb in connection with this study and the development of this manuscript. WSJ has research grants from the Agency for Healthcare Research and Quality, AstraZeneca, American Heart Association, Bristol-Myers Squibb, Doris Duke Charitable Foundation, Merck, and the Patient-Centered Outcomes Research Institute, and Honoraria/other from the American College of Physicians, Bayer, Bristol-Myers Squibb, Daiichi Sankyo, and Janssen Pharmaceuticals. JS has received consultant or speaker fees, or both, from Amgen, Astra-Zeneca, Atricure, Bayer, Biosense Webster, Biotronik, Boehringer-Ingelheim, Boston Scientific, Bristol-Myers Squibb, Cook Medical, Daiichi Sankyo, Medtronic, Novartis, Pfizer, Sanofi-Aventis, Sorin, St. Jude Medical/Abbott, and Zoll. He reports ownership of CorXL.; JS has received grant support through his institution from Bayer Healthcare, Biosense Webster, Biotronik, Boston Scientific, Daiichi Sankyo, Medtronic, and St. Jude Medical/Abbott. OB has no conflicts to disclose.
Authorship: All authors had access to the data and have read and approved this submission. All authors meet the criteria for authorship. In drafting, writing, and reviewing our article, the authors followed International Committee of Medical Journal Editors guidelines.
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Access this article on ScienceDirectLinked Article
- Corrigendum to “Effectiveness and Safety of Oral Anticoagulants in Adults with Non-valvular Atrial Fibrillation Patients and Concomitant Coronary/Peripheral Artery Disease” American Journal of Medicine 131:09 (2018): 1074-1085.e4The American Journal of MedicineVol. 133Issue 10
- PreviewThere were 33,269 apixaban-warfarin, 9,345 dabigatran-warfarin, and 42,156 rivaroxaban-warfarin matched pairs, with a median follow-up of 4-5 months. Compared with warfarin, apixaban was associated with lower rates of stroke/systemic embolism (hazard ratio [HR] 0.52; 95% confidence interval [95% CI], 0.43-0.62), major bleeding (HR 0.60; 95% CI, 0.55-0.66) and stroke/myocardial infarction/all-cause mortality (HR 0.70; 95%CI, 0.66-0.74); dabigatran was associated with lower rates of major bleeding (HR: 0.73; 95% CI, 0.62-0.85); dabigatran and rivaroxaban were associated with lower rates of stroke/myocardial infarction/all-cause mortality (HR 0.77; 95% CI, 0.69-0.86 and HR 0.81; 95% CI, 0.77-0.85, respectively).
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