Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin Among Adults With Cancer and Atrial Fibrillation.

IF 6.9 2区医学

Circulation. Cardiovascular Quality and Outcomes Pub Date : 2022-12-01 DOI:10.1161/CIRCOUTCOMES.122.008951

Hemalkumar B Mehta, Huijun An, Shirin Ardeshirrouhanifard, Mukaila A Raji, G Caleb Alexander, Jodi B Segal

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引用次数: 3

Abstract

Background: While clinical guidelines recommend direct-acting oral anticoagulants (DOAC) over warfarin to treat isolated nonvalvular atrial fibrillation, guidelines are silent regarding nonvalvular atrial fibrillation treatment among individuals with cancer, reflecting the paucity of evidence in this setting. We quantified relative risk of ischemic stroke or systemic embolism and major bleeding (primary outcomes), and all-cause and cardiovascular death (secondary outcomes) among older individuals with cancer and nonvalvular atrial fibrillation comparing DOACs and warfarin.

Methods: This retrospective cohort study used Surveillance, Epidemiology, and End Results cancer registry and linked US Medicare data from 2010 through 2016, and included individuals diagnosed with cancer and nonvalvular atrial fibrillation who newly initiated DOAC or warfarin. We used inverse probability of treatment weighting to control confounding. We used competing risk regression for primary outcomes and cardiovascular death, and Cox proportional hazard regression for all-cause death.

Results: Among 7675 individuals included in the cohort, 4244 (55.3%) received DOACs and 3431 (44.7%) warfarin. In the inverse probability of treatment weighting analysis, there was no statistically significant difference among DOAC and warfarin users in the risk of ischemic stroke or systemic embolism (1.24 versus 1.19 events per 100 person-years, adjusted hazard ratio 1.41 [95% CI, 0.92-2.14]), major bleeding (3.08 versus 4.49 events per 100 person-years, adjusted hazard ratio 0.90 [95% CI, 0.70-1.17]), and cardiovascular death (1.88 versus 3.14 per 100 person-years, adjusted hazard ratio 0.82 [95% CI, 0.59-0.1.13]). DOAC users had significantly lower risk of all-cause death (7.09 versus 13.3 per 100 person-years, adjusted hazard ratio 0.81 [95% CI, 0.69-0.94]) compared to warfarin users.

Conclusions: Older adults with cancer and atrial fibrillation exposed to DOACs had similar risks of stroke and systemic embolism and major bleeding as those exposed to warfarin. Relative to warfarin, DOAC use was associated with a similar risk of cardiovascular death and a lower risk of all-cause death.

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成人癌症合并心房颤动患者直接口服抗凝剂与华法林的有效性和安全性比较。

背景:虽然临床指南推荐直接作用口服抗凝剂(DOAC)而不是华法林治疗孤立性非瓣膜性房颤，但指南对癌症患者的非瓣膜性房颤治疗保持沉默，这反映了在这种情况下证据的缺乏。我们量化了老年癌症和非瓣膜性心房颤动患者的缺血性卒中或全系统栓塞和大出血(主要结局)以及全因和心血管死亡(次要结局)的相对风险，比较DOACs和华法林。方法:这项回顾性队列研究使用2010年至2016年的监测、流行病学和最终结果癌症登记和相关的美国医疗保险数据，包括新开始DOAC或华法林的诊断为癌症和非瓣膜性心房颤动的个体。我们使用处理加权的逆概率来控制混淆。我们对主要结局和心血管死亡使用竞争风险回归，对全因死亡使用Cox比例风险回归。结果:在纳入队列的7675人中，4244人(55.3%)接受了doac治疗，3431人(44.7%)接受了华法林治疗。在治疗加权逆概率分析中，DOAC和华法林使用者在缺血性卒中或全系统栓塞(1.24 vs 1.19事件/ 100人-年，校正风险比1.41 [95% CI, 0.92-2.14])、大出血(3.08 vs 4.49事件/ 100人-年，校正风险比0.90 [95% CI, 0.70-1.17])和心血管死亡(1.88 vs 3.14 / 100人-年，校正风险比0.82 [95% CI，0.59 0.1.13])。与华法林服用者相比，DOAC服用者的全因死亡风险显著降低(7.09 vs 13.3 / 100人-年，校正风险比0.81 [95% CI, 0.69-0.94])。结论:老年癌症和房颤患者暴露于DOACs与暴露于华法林的患者卒中、全身性栓塞和大出血的风险相似。与华法林相比，DOAC的使用与心血管死亡风险相似，全因死亡风险较低。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Circulation. Cardiovascular Quality and Outcomes Medicine-Cardiology and Cardiovascular Medicine

CiteScore

9.80

自引率

2.90%

发文量

357

期刊介绍： Circulation: Cardiovascular Quality and Outcomes, an American Heart Association journal, publishes articles related to improving cardiovascular health and health care. Content includes original research, reviews, and case studies relevant to clinical decision-making and healthcare policy. The online-only journal is dedicated to furthering the mission of promoting safe, effective, efficient, equitable, timely, and patient-centered care. Through its articles and contributions, the journal equips you with the knowledge you need to improve clinical care and population health, and allows you to engage in scholarly activities of consequence to the health of the public. Circulation: Cardiovascular Quality and Outcomes considers the following types of articles: Original Research Articles, Data Reports, Methods Papers, Cardiovascular Perspectives, Care Innovations, Novel Statistical Methods, Policy Briefs, Data Visualizations, and Caregiver or Patient Viewpoints.