The Cardiovascular Department (Y.-H.C., L.-S.W., S.-H.C., Y.-H.Y., C.-T.K.), Chang Gung Memorial Hospital, Linkou, Taiwan.
Microscopy Core Laboratory (Y.-H.C.), Chang Gung Memorial Hospital, Linkou, Taiwan.
Stroke. 2021 Oct;52(10):3132-3141. doi: 10.1161/STROKEAHA.120.033470. Epub 2021 Jul 8.
Data on clinical outcomes for nonvitamin K antagonist oral anticoagulant (NOACs) and warfarin in patients with atrial fibrillation and cancer are limited, and patients with active cancer were excluded from randomized trials. We investigated the effectiveness and safety for NOACs versus warfarin among patients with atrial fibrillation with cancer.
In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database, we identified a total of 6274 and 1681 consecutive patients with atrial fibrillation with cancer taking NOACs and warfarin from June 1, 2012, to December 31, 2017, respectively. Propensity score stabilized weighting was used to balance covariates across study groups.
There were 1031, 1758, 411, and 3074 patients treated with apixaban, dabigatran, edoxaban, and rivaroxaban, respectively. After propensity score stabilized weighting, NOAC was associated with a lower risk of major adverse cardiovascular events (hazard ratio, 0.63 [95% CI, 0.50–0.80]; P=0.0001), major adverse limb events (hazard ratio, 0.41 [95% CI, 0.24–0.70]; P=0.0010), venous thrombosis (hazard ratio, 0.37 [95% CI, 0.23–0.61]; P<0.0001), and major bleeding (hazard ratio, 0.73 [95% CI, 0.56–0.94]; P=0.0171) compared with warfarin. The outcomes were consistent with either direct thrombin inhibitor (dabigatran) or factor Xa inhibitor (apixaban, edoxaban, and rivaroxaban) use, among patients with stroke history, and among patients with different type of cancer and local, regional, or metastatic stage of cancer (P interaction >0.05). When compared with warfarin, NOAC was associated with lower risk of major adverse cardiovascular event, and venous thrombosis in patients aged <75 but not in those aged ≥75 years (P interaction <0.05).
Thromboprophylaxis with NOACs rather than warfarin should be considered for the majority of the atrial fibrillation population with cancer.
关于非维生素 K 拮抗剂口服抗凝剂（NOACs）和华法林在伴有癌症的心房颤动患者中的临床结局数据有限，并且随机试验排除了伴有活动性癌症的患者。我们调查了在伴有癌症的心房颤动患者中，NOACs 与华法林的有效性和安全性。
在这项来自台湾全民健康保险研究数据库的全国性回顾性队列研究中，我们分别于 2012 年 6 月 1 日至 2017 年 12 月 31 日，确定了 6274 例和 1681 例连续接受 NOAC 和华法林治疗的伴有癌症的心房颤动患者。采用倾向评分稳定加权法来平衡研究组间的协变量。
分别有 1031、1758、411 和 3074 例患者接受了阿哌沙班、达比加群、依度沙班和利伐沙班治疗。在进行倾向评分稳定加权后，与华法林相比，NOAC 与较低的主要不良心血管事件（风险比，0.63[95%置信区间，0.50-0.80]；P=0.0001）、主要不良肢体事件（风险比，0.41[95%置信区间，0.24-0.70]；P=0.0010）、静脉血栓形成（风险比，0.37[95%置信区间，0.23-0.61]；P<0.0001）和大出血（风险比，0.73[95%置信区间，0.56-0.94]；P=0.0171）风险相关，且结果与有卒中史的患者中使用直接凝血酶抑制剂（达比加群）或因子 Xa 抑制剂（阿哌沙班、依度沙班和利伐沙班）或无卒中史的患者中一致，与不同类型癌症和局部、区域或转移性癌症分期的患者中一致（P 交互>0.05）。与华法林相比，NOAC 在年龄<75 岁的患者中与较低的主要不良心血管事件和静脉血栓形成风险相关，但在年龄≥75 岁的患者中不相关（P 交互<0.05）。
对于大多数伴有癌症的心房颤动患者，应考虑使用 NOAC 进行血栓预防，而非华法林。
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