Zalesak Martin, Siu Kimberly, Francis Kevin, Yu Chen, Alvrtsyan Hasmik, Rao Yajing, Walker David, Sander Stephen, Miyasato Gavin, Matchar David, Sanchez Herman
Trinity Partners, Waltham, MA.
Circ Cardiovasc Qual Outcomes. 2013 Sep 1;6(5):567-74. doi: 10.1161/CIRCOUTCOMES.113.000192. Epub 2013 Aug 6.
Oral anticoagulation therapy is the primary tool in reducing stroke risk in patients with nonvalvular atrial fibrillation but is underused. Patients nonpersistent with therapy contribute to this underuse. The objective of this study was to compare persistence rates in newly diagnosed nonvalvular atrial fibrillation patients treated with warfarin versus dabigatran as their oral anticoagulation.
US Department of Defense administrative claims were used to identify patients receiving warfarin or dabigatran between October 28, 2010, and June 30, 2012. Patient records were examined for a minimum of 12 months before index date to restrict the analyses to those newly diagnosed with nonvalvular atrial fibrillation and naive-to-treatment, identifying 1775 on warfarin and 3370 on dabigatran. Propensity score matching was used to identify 1745 matched pairs. Persistence was defined as time on therapy to discontinuation. Kaplan-Meier curves were used to depict persistence over time. Cox proportional hazards model was used to determine the factors significantly associated with persistence. Using a 60-day permissible medication gap, the persistence rates were higher for dabigatran than for warfarin at both 6 months (72% versus 53%) and 1 year (63% versus 39%). Patients on dabigatran with a low-to-moderate risk of stroke (CHADS2<2) or with a higher bleed risk (HEMORR2HAGES>3) had a higher likelihood of nonpersistence (hazard ratios, 1.37; 95% confidence interval, 1.17-1.60; P<0.001; and hazard ratios, 1.24; 95% confidence interval, 1.04-1.47; P=0.016).
Patients who initiated dabigatran treatment were more persistent than patients who began warfarin treatment. Within each cohort, patients with lower stroke risk were more likely to discontinue therapy.
口服抗凝治疗是降低非瓣膜性心房颤动患者中风风险的主要手段，但未得到充分利用。治疗不持续的患者导致了这种未充分利用的情况。本研究的目的是比较新诊断的非瓣膜性心房颤动患者使用华法林与达比加群作为口服抗凝药的治疗持续率。
利用美国国防部行政索赔数据来识别2010年10月28日至2012年6月30日期间接受华法林或达比加群治疗的患者。在索引日期前至少检查12个月的患者记录，以将分析限制在新诊断为非瓣膜性心房颤动且未接受过治疗的患者，确定1775例使用华法林的患者和3370例使用达比加群的患者。采用倾向评分匹配法确定1745对匹配对。持续率定义为从治疗开始到停药的时间。采用Kaplan-Meier曲线描绘随时间的持续率。使用Cox比例风险模型确定与持续率显著相关的因素。使用60天的允许用药间隔，达比加群在6个月（72%对53%）和1年（63%对39%）时的持续率均高于华法林。中风风险低至中度（CHADS2<2）或出血风险较高（HEMORR2HAGES>3）的达比加群治疗患者不持续治疗的可能性更高（风险比分别为1.37；95%置信区间为1.17-1.60；P<0.001；以及风险比为1.24；95%置信区间为1.04-1.47；P=0.016）。
开始使用达比加群治疗的患者比开始使用华法林治疗的患者治疗更持续。在每个队列中，中风风险较低的患者更有可能停止治疗。
