Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan; General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan.
Heart Rhythm. 2021 Jun;18(6):871-877. doi: 10.1016/j.hrthm.2021.02.018. Epub 2021 Feb 25.
The prevalence and incidence of atrial fibrillation (AF) increase with age. However, older patients often are denied oral anticoagulation (OAC), especially if they are "very elderly" (age ≥90 years) and perceived to be high risk for bleeding, for example, those with a history of intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), or chronic kidney disease.
The purpose of this study was to investigate the effectiveness and safety of OAC in this high-risk, very elderly group.
We used the Taiwan National Health Insurance Research Database to identify high-risk, very elderly subjects taking OAC, either warfarin or a non-vitamin K antagonist oral anticoagulant (NOAC), and compared them to non-OAC users for the composite net clinical endpoint of ischemic stroke, ICH, major bleeding, or mortality.
We studied 7362 subjects (mean age 92.5 years), of whom 1737 were taking NOACs, 670 warfarin, and 4955 non-OACs. Compared to non-OACs, warfarin was associated with a higher risk of the composite endpoint (adjusted hazard ratio [aHR] 1.163; 95% confidence interval [CI] 1.052-1.287), whereas NOACs were associated with a lower risk (aHR 0.763; 95% CI 0.702-0.830). After propensity matching, NOACs were associated with a lower risk of events compared to non-OACs or warfarin, whereas warfarin had a similar risk compared to non-OACs.
Warfarin was associated with a similar or even higher risk of composite clinical outcomes compared to non-OACs. NOACs were associated with a lower risk of composite endpoint compared to warfarin or non-OACs, and their use still should be considered in these high-risk, very elderly AF patients.
心房颤动（房颤）的患病率和发病率随年龄增长而增加。然而，老年患者常常被拒绝使用口服抗凝药物（OAC），特别是如果他们是“非常高龄”（年龄≥90 岁），并且被认为有出血高风险，例如有颅内出血（ICH）、胃肠道出血（GIB）或慢性肾脏病病史的患者。
本研究旨在调查在这一高风险、非常高龄的群体中使用 OAC 的有效性和安全性。
我们使用台湾全民健康保险研究数据库，确定正在服用 OAC（华法林或非维生素 K 拮抗剂口服抗凝剂（NOAC））的高危、非常高龄患者，并将他们与未使用 OAC 的患者进行比较，复合终点为缺血性脑卒中、ICH、大出血或死亡。
我们研究了 7362 名患者（平均年龄 92.5 岁），其中 1737 名患者服用 NOAC，670 名患者服用华法林，4955 名患者未使用 OAC。与未使用 OAC 相比，华法林与复合终点的风险更高（调整后的危险比[aHR]1.163；95%置信区间[CI]1.052-1.287），而 NOAC 与风险降低相关（aHR0.763；95%CI0.702-0.830）。经过倾向匹配后，NOAC 与事件风险降低相关，与未使用 OAC 或华法林相比，而华法林与未使用 OAC 的风险相似。
与未使用 OAC 相比，华法林与复合临床结局的风险相似甚至更高。与华法林或未使用 OAC 相比，NOAC 与复合终点风险降低相关，在这些高风险、非常高龄的房颤患者中仍应考虑使用。
