Efficacy and safety of dabigatran, rivaroxaban, and warfarin for stroke prevention in Chinese patients with atrial fibrillation: the Hong Kong Atrial Fibrillation Project

Abstract

Background Little is known about the comparative effectiveness and safety of non–vitamin K antagonist oral anticoagulants (NOAC) compared to warfarin in Chinese atrial fibrillation (AF) patients. Our aim was to compare the ischemic stroke risk reduction and incidence of intracranial hemorrhage (ICH) of warfarin in relation to quality of anticoagulation control (as reflected by time in therapeutic range [TTR]), and to dabigatran and rivaroxaban in a real‐world cohort of Chinese AF patients. Hypothesis NOAC, rather than warfarin, is preferred in Chinese AF patients. Methods Of 2099 patients studied (73.1 ± 12.3 years, female: 44.6%, CHA2DS2‐VASc 3.7 ± 1.9 and HAS‐BLED 2.0 ± 1.0) with nonvalvular AF, 963 patients (45.9%) were on warfarin (only 16.3% had TTR ≥65%), 669 patients were on rivaroxaban, and 467 patients were on dabigatran. Results After a mean follow‐up of 21.7 ± 13.4 months, there were 156 ischemic strokes (annual incidence of 4.10%/year), with the incidence of ischemic stroke being highest in patients on warfarin with TTR <65% (5.24%/year), followed by those on rivaroxaban (3.74%/year), and those on warfarin with TTR ≥65% (3.35%/year), whereas patients on dabigatran had the lowest incidence of ischemic stroke (1.89%/year). The incidence of ICH was lowest in patients on dabigatran (0.39%/year) compared with those on rivaroxaban (0.52%/year) and warfarin, with TTR <65% (0.95%/year) and TTR ≥65% (0.58%/year). Patients on rivaroxaban 20 mg daily had similar ischemic stroke risk (1.93%/year) and ICH risk (0.21%/year) compared to dabigatran. Conclusions In Chinese AF patients, the benefits of warfarin therapy for stroke prevention and ICH reduction depend on TTR. Of the treatments compared, dabigatran, as well as rivaroxaban 20 mg daily, was associated with lowest ischemic stroke and ICH rates.

Standard and reduced doses of dabigatran, rivaroxaban and apixaban for stroke prevention in atrial fibrillation: a nationwide cohort study

“…Contrary, a Chinese study estimated a lower associated risk of ischaemic stroke for dabigatran 110 mg compared with rivaroxaban 15 mg and 20 mg . The American and Chinese studies were restricted to only compare rivaroxaban versus dabigatran, whereas a recently published American study by Noseworthy et al . compared dabigatran, rivaroxaban and apixaban in three one‐to‐one propensity‐score‐matched cohorts.…”

“…Similar to our results, the two American studies found no significant difference in associated stroke risk between rivaroxaban and dabigatran. Contrary, a Chinese study estimated a lower associated risk of ischaemic stroke for dabigatran 110 mg compared with rivaroxaban 15 mg and 20 mg . The American and Chinese studies were restricted to only compare rivaroxaban versus dabigatran, whereas a recently published American study by Noseworthy et al .…”

“…29] whereas a recently published American study by Noseworthy et al compared dabigatran, rivaroxaban and apixaban in three one-to-one propensity-score-matched cohorts. The study found no difference in associated risk of stroke in the pairwise comparisons[30].…”

Efficacy and Safety of Apixaban, Dabigatran, Rivaroxaban, and Warfarin in Asians With Nonvalvular Atrial Fibrillation

“…The J‐ROCKET AF trial (Japanese Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) showed that the pharmacokinetic profiles of a 15‐mg dose of rivaroxaban in Japanese patients was similar to the 20‐mg dose in white patients, indicating that low‐dose rivaroxaban with 15/10 mg is adequate for stroke prevention in AF patients 35. Chan et al also reported that low‐dose dabigatran was associated with the lowest risk of ischemic stroke and ICH compared with warfarin with a variety of quality controls in elderly Chinese with AF 36, 37, 38. Further studies are warranted to determine the so‐called “optimal” dose of NOACs in Asians with AF.…”

“…35 Chan et al also reported that low-dose dabigatran was associated with the lowest risk of ischemic stroke and ICH compared with warfarin with a variety of quality controls in elderly Chinese with AF. [36][37][38] Further studies are warranted to determine the so-called "optimal" dose of NOACs in Asians with AF.…”