1 Division of Cardiology, Cook County Health and Hospital System, Chicago, IL, USA.
2 Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
J Cardiovasc Pharmacol Ther. 2019 Sep;24(5):428-434. doi: 10.1177/1074248419841634. Epub 2019 Apr 29.
Direct oral anticoagulants (DOACs) have been found to be similar or superior to warfarin in reducing ischemic stroke and intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF). We sought to examine the anticoagulation prescription patterns in community since the advent of DOACs and also evaluate the outcomes in terms of gastrointestinal (GI) bleeding, ischemic stroke, and ICH in real-world patients with AF receiving anticoagulation.
This is a retrospective study comprising patients who were newly diagnosed with nonvalvular AF and were prescribed anticoagulants for stroke prevention. Prescription pattern of the anticoagulants based on CHADSVasc score was studied. Clinical outcomes of GI bleeding, ischemic stroke, and ICH were analyzed using a multivariate logistic regression model.
Of the 2362 patients with AF on anticoagulation, 44.7% were prescribed DOACs. Patients with CHADSVASc score of ≥3 received a prescription for warfarin more often than DOACs ( < .001). Multivariate logistic regression analysis revealed that the incidence of GI bleed (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.62-1.35, = .66) and stroke (OR: 0.77, 95% CI: 0.57-1.05, = .10) was similar between warfarin and DOAC users. However, there was a trend toward lower ICH in the DOAC group (OR: 0.60, 95% CI: 0.36-1.01, = .06).
Prescription rate of DOACs for nonvalvular AF has increased significantly, with apixaban being the most commonly used agent. Patients with higher CHADS-VASc score (≥3) are prescribed DOACs less often than warfarin. The reason for this discrepancy is unclear. Given the favorable risk-benefit profile of DOACs, further studies are needed to identify factors that determine anticoagulant selection in patients with AF with high thromboembolic risk.
直接口服抗凝剂（DOAC）在降低房颤（AF）患者的缺血性卒中和颅内出血（ICH）方面已被证明与华法林相似或优于华法林。我们旨在研究 DOAC 问世后社区中的抗凝治疗模式，并评估真实世界中接受抗凝治疗的 AF 患者的胃肠道（GI）出血、缺血性卒中和 ICH 结局。
这是一项回顾性研究，纳入了新诊断为非瓣膜性 AF 并接受卒中预防抗凝治疗的患者。根据 CHADSVasc 评分研究抗凝药物的处方模式。使用多变量逻辑回归模型分析 GI 出血、缺血性卒中和 ICH 的临床结局。
在 2362 名接受抗凝治疗的 AF 患者中，44.7%的患者服用 DOAC。CHADSVASc 评分≥3 的患者服用华法林的处方多于 DOAC（<0.001）。多变量逻辑回归分析显示，华法林和 DOAC 使用者的 GI 出血发生率（比值比 [OR]：0.91，95%置信区间 [CI]：0.62-1.35，=0.66）和卒中发生率（OR：0.77，95% CI：0.57-1.05，=0.10）相似。然而，DOAC 组的 ICH 发生率呈下降趋势（OR：0.60，95% CI：0.36-1.01，=0.06）。
非瓣膜性 AF 中 DOAC 的处方率显著增加，阿哌沙班是最常用的药物。CHADS-VASc 评分较高（≥3）的患者服用 DOAC 的频率低于华法林。这种差异的原因尚不清楚。鉴于 DOAC 的有利风险效益比，需要进一步研究确定高血栓栓塞风险的 AF 患者中决定抗凝药物选择的因素。
