Lee So-Ryoung, Choi Eue-Keun, Kwon Soonil, Jung Jin-Hyung, Han Kyung-Do, Cha Myung-Jin, Oh Seil, Lip Gregory Y H
Department of Internal Medicine, Seoul National University Hospital, Republic of Korea (S.-R.L., E.-K.C., S.K., M.-J.C., S.O.).
Department of Medical Statistics, College of Medicine, Catholic University of Korea, Republic of Korea (J.-H.J., K.-D.H.).
Circ Cardiovasc Qual Outcomes. 2020 Mar;13(3):e005894. doi: 10.1161/CIRCOUTCOMES.119.005894. Epub 2020 Mar 12.
Background Since the direct oral anticoagulants (DOAC) were introduced, oral anticoagulant (OAC) prescription patterns have rapidly changed in patients with atrial fibrillation (AF). We aimed to evaluate the evolving trends of OAC use in a large nationwide cohort and specifically examine the changes in patient profiles treated with warfarin or DOAC and whether the time trends in OAC use affected clinical outcomes. Methods and Results Using the Korean Health Insurance Review and Assessment database, we divided OAC naive patients with AF into 3 groups according to the enrollment period between January 2015 and December 2017 (n=35 353 in cohort 1, n=36 631 in cohort 2, and n=44 819 in cohort 3). DOAC use increased from 59% to 89%, whereas warfarin use has decreased from 41% to 11% during the study period. Patients treated with warfarin were increasingly younger from cohort 1 to cohort 3 (mean age 68-65 years, <0.001) with lower mean CHADS-VASc scores (3.3-2.9, <0.001), whereas those with DOAC did not show a significant difference in clinical characteristics over the study period. Warfarin group had improved clinical outcomes over time, reflecting dynamic changes in patient characteristics. Compared with warfarin group, unadjusted hazard ratios of composite outcome for DOAC group have changed over time (hazard ratio 0.77 [95% CI, 0.69-0.85] in cohort 1, hazard ratio 0.84 [95% CI, 0.73-0.97] in cohort 2, and hazard ratio 1.00 [95% CI, 0.78-1.25] in cohort 3). After propensity score weighting between warfarin and DOAC groups in each cohort, DOAC showed consistently lower risks of the composite outcome by approximately 23% to 25% compared with warfarin across 3 different periods. Conclusions In contemporary clinical practice, OAC prescription patterns and characteristics of patients treated warfarin or DOAC have dynamically changed. Despite these changes, DOAC showed a consistent better net clinical benefit compared with warfarin across different periods.
背景 自从直接口服抗凝剂（DOAC）问世以来，心房颤动（AF）患者的口服抗凝剂（OAC）处方模式迅速改变。我们旨在评估一个大型全国性队列中OAC使用的演变趋势，并特别研究接受华法林或DOAC治疗的患者特征变化，以及OAC使用的时间趋势是否影响临床结局。方法和结果 使用韩国健康保险审查与评估数据库，我们根据2015年1月至2017年12月的入组时间将初治AF且未使用OAC的患者分为3组（队列1中有35353例，队列2中有36631例，队列3中有44819例）。在研究期间，DOAC的使用从59%增加到89%，而华法林的使用从41%下降到11%。从队列1到队列3，接受华法林治疗的患者年龄越来越小（平均年龄68 - 65岁，P<0.001），平均CHADS - VASc评分更低（3.3 - 2.9，P<0.001），而接受DOAC治疗的患者在研究期间临床特征无显著差异。随着时间推移，华法林组的临床结局有所改善，这反映了患者特征的动态变化。与华法林组相比，DOAC组复合结局的未调整风险比随时间变化（队列1中风险比为0.77[95%CI，0.69 - 0.85]，队列2中风险比为0.84[95%CI，0.73 - 0.97]，队列3中风险比为1.00[95%CI，0.78 - 1.25]）。在每个队列的华法林组和DOAC组之间进行倾向评分加权后，在3个不同时期，DOAC与华法林相比，复合结局风险始终低约23%至25%。结论 在当代临床实践中，OAC处方模式以及接受华法林或DOAC治疗的患者特征发生了动态变化。尽管有这些变化，但在不同时期，DOAC与华法林相比显示出持续更好的净临床获益。
