Effectiveness and Safety of Direct Oral Anticoagulants Among Patients with Non-valvular Atrial Fibrillation and Multimorbidity

Abstract

Introduction: In the USA, there is a steady rise of atrial fibrillation due to the aging population with increased morbidity. This study evaluated the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) among elderly patients with non-valvular atrial fibrillation (NVAF) and multimorbidity prescribed direct oral anticoagulants (DOACs). Methods: Using the CMS Medicare database, a retrospective observational study of adult patients with NVAF and multimorbidity who initiated apixaban, dabigatran, or rivaroxaban from January 1, 2012 to December 31, 2017 was conducted. High multimorbidity was classified as having C 6 comorbidities. Cox proportional hazard models were used to evaluate the hazard ratios of S/SE and MB among three 1:1 propensity score matched DOAC cohorts. All-cause healthcare costs were estimated using generalized linear models. Results: Overall 36% of the NVAF study population had high multimorbidity, forming three propensity score matched (PSM) cohorts: 12,511 apixaban-dabigatran, 60,287 apixabanrivaroxaban, and 12,567 dabigatran-rivaroxaban patients. Apixaban was associated with a lower risk of stroke/SE and MB when compared with dabigatran and rivaroxaban. Dabigatran had a lower risk of stroke/SE and a similar risk of MB when compared with rivaroxaban. Compared to rivaroxaban, apixaban patients incurred lower all-cause healthcare costs, and dabigatran patients incurred similar all-cause healthcare costs. Compared to dabigatran, apixaban patients incurred similar all-cause healthcare costs. Conclusion: Patients with NVAF and C 6 comorbid conditions had significantly different risks for stroke/SE and MB when comparing DOACs to DOACs, and different healthcare expenses. This study's results may be useful for evaluating the risk-benefit ratio of DOAC use in patients with NVAF and multimorbidity.

Rivaroxaban Versus Apixaban: A Comparison Without a Simple Solution

“…The original randomized ROCKET AF trial 3 , 4 and ARISTOTLE 7 trial had median follow-ups of 1.6 and 1.8 years, respectively. In many of the recent observational studies we reviewed, 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 many had follow-up durations of only 3 to 6 months. All major outcomes in ROCKET AF trial 3 , 4 and ARISTOTLE 7 vs vitamin K antagonists were adjudicated by committee members who were blinded to treatment allocation.…”

“…A total of 339 studies were initially identified of which 230 studies were excluded based on the exclusion criteria. On review of the remaining 109 studies, full texts were reviewed, and 41 studies were included for final review 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ( Figure 1 ). Not all studies reviewed are referenced further.…”

Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal

“… 338 On the contrary, in two very large claim-based and propensity score-matched analyses exploring the interaction between NOACs, VKAs, and multi-morbidity, all data strongly underline how apixaban seems to have a better effectiveness and safety profile compared to warfarin, dabigatran, and rivaroxaban in multi-morbid AF patients. 339 , 340 …”

Idarucizumab in dabigatran-treated patients with acute stroke: a review and clinical update

“…This result is even more concerning since exposure outside of on-therapy ranges is known to be related to stroke and bleeding events. Nevertheless, real-life clinical data support the safety of dabigatran even in high-risk groups ( 32 , 33 ), which is further increased by the availability of its specific antidote idarucizumab.…”