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Lip GYH, Keshishian AV, Kang AL, Dhamane AD, Luo X, Li X, Balachander N, Rosenblatt L, Mardekian J, Pan X, Di Fusco M, Garcia Reeves AB, Yuce H, Deitelzweig S. Oral anticoagulants for nonvalvular atrial fibrillation in frail elderly patients: insights from the ARISTOPHANES study. J Intern Med 2021; 289:42-52. [PMID: 32602228 DOI: 10.1111/joim.13140] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/29/2020] [Accepted: 06/08/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patient frailty amongst patients with nonvalvular atrial fibrillation (NVAF) is associated with adverse health outcomes and increased risk of mortality. Additional evidence is needed to evaluate effective and safe NVAF treatment in this patient population. OBJECTIVES This subgroup analysis of the ARISTOPHANES study compared the risk of stroke/systemic embolism (S/SE) and major bleeding (MB) amongst frail NVAF patients prescribed nonvitamin K antagonist oral anticoagulants (NOACs) or warfarin. METHODS This comparative retrospective observational study of frail, older NVAF patients who initiated apixaban, dabigatran, rivaroxaban or warfarin from 01JAN2013-30SEP2015 was conducted using Medicare and 3 US commercial claims databases. To compare each drug, 6 propensity score-matched (PSM) cohorts were created. Patient cohorts were pooled from 4 databases after PSM. Cox models were used to estimate hazard ratios (HR) of S/SE and MB. RESULTS Amongst NVAF patients, 34% (N = 150 487) met frailty criteria. Apixaban and rivaroxaban were associated with a lower risk of S/SE vs warfarin (apixaban: HR: 0.61, 95% CI: 0.55-0.69; rivaroxaban: HR: 0.79, 95% CI: 0.72-0.87). For MB, apixaban (HR: 0.62, 95% CI: 0.57-0.66) and dabigatran (HR: 0.79, 95% CI: 0.70-0.89) were associated with a lower risk and rivaroxaban (HR: 1.14, 95% CI: 1.08-1.21) was associated with a higher risk vs warfarin. CONCLUSION Amongst this cohort of frail NVAF patients, NOACs were associated with varying rates of stroke/SE and MB compared with warfarin. Due to the lack of real-world data regarding OAC treatment in frail patients, these results may inform clinical practice in the treatment of this patient population.
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Affiliation(s)
- G Y H Lip
- From the, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A V Keshishian
- STATinMED Research, Ann Arbor, MI, USA.,New York City College of Technology (CUNY), New York, NY, USA
| | - A L Kang
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - A D Dhamane
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - X Luo
- Pfizer, Inc., Groton, CT, USA
| | - X Li
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - N Balachander
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | - L Rosenblatt
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - X Pan
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA
| | | | - A B Garcia Reeves
- Bristol-Myers Squibb Company, Lawrenceville, NJ, USA.,University of North Carolina, Chapel Hill, NC, USA
| | - H Yuce
- New York City College of Technology (CUNY), New York, NY, USA
| | - S Deitelzweig
- Department of Hospital Medicine, Ochsner Clinic Foundation, New Orleans, LA, USA.,Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
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Best JG, Bell R, Haque M, Chandratheva A, Werring DJ. Atrial fibrillation and stroke: a practical guide. Pract Neurol 2019; 19:208-224. [PMID: 30826740 DOI: 10.1136/practneurol-2018-002089] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Neurologists and stroke physicians will be familiar with atrial fibrillation as a major cause of ischaemic stroke, and the role of anticoagulation in preventing cardioembolic stroke. However, making decisions about anticoagulation for individual patients remains a difficult area of clinical practice, balancing the serious risk of ischaemic stroke against that of major bleeding, particularly intracranial haemorrhage. Atrial fibrillation management requires interdisciplinary collaboration with colleagues in cardiology and haematology. Recent advances, especially the now-widespread availability of direct oral anticoagulants, have brought opportunities to improve stroke care while posing new challenges. This article gives an overview of the contemporary diagnosis and management of atrial fibrillation, and the associated evidence base. Where there is uncertainty, we describe our own approach to these areas, while highlighting ongoing research that will likely guide future practice.
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Affiliation(s)
- Jonathan Gordon Best
- Stroke Research Centre, University College London Queen Square Institute of Neurology, London, UK
| | - Robert Bell
- Institute of Cardiovascular Science, University College London, London, UK
| | - Mohammed Haque
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Arvind Chandratheva
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - David John Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, London, UK .,Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
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