Kailas Shilpa D, Thambuluru Sirisha Reddy
University of Central Florida College of Medicine.
Cureus. 2016 Oct 18;8(10):e836. doi: 10.7759/cureus.836.
Direct oral anticoagulants (DOACs), previously also known as novel oral anticoagulants (NOACs), have increased the therapeutic options for stroke prevention in atrial fibrillation (AF). Previous studies comparing their relative efficacy and safety do not address age-related differences, such as comorbidities and physical and social boundaries. This review aimed to summarize and compare the clinical and safety outcomes of DOACs and warfarin for stroke prevention in AF in the elderly population (≥ 65 years). We searched PubMed for randomized controlled trials and meta-analyses that compared DOACs and warfarin in elderly patients with AF. Stroke and systemic embolism (SSE) and major bleeding (MB) were primary outcomes. Secondary outcomes included ischemic stroke, all-cause mortality, intracranial bleeding, and gastrointestinal bleeding. Of 66 studies identified, one randomized control trial (RCT) and one meta-analysis were included. DOACs were at least as effective at reducing the risk of SSE as warfarin. DOACs demonstrated a minimal benefit for ischemic stroke (dabigatran, 110 mg, relative risk (RR) 1.08; edoxaban, 60 mg, RR 1.00; and apixaban, 5 mg, RR 0.99). DOACs associated with decreased risk of MB relative to warfarin include dabigatran, 110 mg; apixaban, 5 mg; and edoxaban, 60 mg (RR 0.80, 0.70, and 0.80, respectively), while dabigatran, 150 mg, and rivaroxaban, 20 mg, increased risk (RR 0.79 - 0.83, respectively). Dabigatran, 110 mg and 150 mg doses, and edoxaban increased the risk of gastrointestinal bleeding (RR 1.04, 1.12, and 1.23, respectively). Lower rates of SSE and intracranial bleeding were seen with DOACs compared to warfarin. Dabigatran, 150 mg, and rivaroxaban, 20 mg, were associated with higher MB in older elderly compared to warfarin. DOACs may be attractive alternatives to warfarin, but further studies are needed to make clinical recommendations.
直接口服抗凝剂（DOACs），以前也被称为新型口服抗凝剂（NOACs），增加了心房颤动（AF）患者预防中风的治疗选择。以往比较它们相对疗效和安全性的研究并未涉及与年龄相关的差异，如合并症以及身体和社会限制。本综述旨在总结和比较DOACs与华法林在老年人群（≥65岁）中预防AF患者中风的临床和安全性结局。我们在PubMed上检索了比较DOACs与华法林用于老年AF患者的随机对照试验和荟萃分析。中风和全身性栓塞（SSE）以及大出血（MB）是主要结局。次要结局包括缺血性中风、全因死亡率、颅内出血和胃肠道出血。在检索到的66项研究中，纳入了一项随机对照试验（RCT）和一项荟萃分析。DOACs在降低SSE风险方面至少与华法林一样有效。DOACs对缺血性中风显示出极小的益处（达比加群110mg，相对风险（RR）1.08；依度沙班60mg，RR 1.00；阿哌沙班5mg，RR 0.99）。与华法林相比，与MB风险降低相关的DOACs包括达比加群110mg、阿哌沙班5mg和依度沙班60mg（RR分别为0.80、0.70和0.80），而达比加群150mg和利伐沙班20mg则增加了风险（RR分别为0.79 - 0.83）。达比加群110mg和150mg剂量以及依度沙班增加了胃肠道出血的风险（RR分别为1.04、1.12和1.23）。与华法林相比，DOACs的SSE和颅内出血发生率较低。与华法林相比，达比加群150mg和利伐沙班20mg在老年患者中与更高的MB相关。DOACs可能是华法林有吸引力的替代药物，但需要进一步研究以提出临床建议。
