Brigham and Women's Hospital, Harvard Medical School, Hebrew SeniorLife, and Beth Israel Deaconess Medical Center, Boston, Massachusetts (D.H.K.).
Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (A.P., J.J.G., L.G.B., H.L., R.J.G., S.S.).
Ann Intern Med. 2021 Sep;174(9):1214-1223. doi: 10.7326/M20-7141. Epub 2021 Jul 20.
The role of differing levels of frailty in the choice of oral anticoagulants for older adults with atrial fibrillation (AF) is unclear.
To examine the outcomes of direct oral anticoagulants (DOACs) versus warfarin by frailty levels.
1:1 propensity score-matched analysis of Medicare data, 2010 to 2017.
Community.
Medicare beneficiaries with AF who initiated use of dabigatran, rivaroxaban, apixaban, or warfarin.
Composite end point of death, ischemic stroke, or major bleeding by frailty levels, defined by a claims-based frailty index.
In the dabigatran-warfarin cohort ( = 158 730; median follow-up, 72 days), the event rate per 1000 person-years was 63.5 for dabigatran initiators and 65.6 for warfarin initiators (hazard ratio [HR], 0.98 [95% CI, 0.92 to 1.05]; rate difference [RD], -2.2 [CI, -6.5 to 2.1]). For nonfrail, prefrail, and frail persons, HRs were 0.81 (CI, 0.68 to 0.97), 0.98 (CI, 0.90 to 1.08), and 1.09 (CI, 0.96 to 1.23), respectively. In the rivaroxaban-warfarin cohort ( = 275 944; median follow-up, 82 days), the event rate per 1000 person-years was 77.8 for rivaroxaban initiators and 83.7 for warfarin initiators (HR, 0.98 [CI, 0.94 to 1.02]; RD, -5.9 [CI, -9.4 to -2.4]). For nonfrail, prefrail, and frail persons, HRs were 0.88 (CI, 0.77 to 0.99), 1.04 (CI, 0.98 to 1.10), and 0.96 (CI, 0.89 to 1.04), respectively. In the apixaban-warfarin cohort ( = 218 738; median follow-up, 84 days), the event rate per 1000 person-years was 60.1 for apixaban initiators and 92.3 for warfarin initiators (HR, 0.68 [CI, 0.65 to 0.72]; RD, -32.2 [CI, -36.1 to -28.3]). For nonfrail, prefrail, and frail persons, HRs were 0.61 (CI, 0.52 to 0.71), 0.66 (CI, 0.61 to 0.70), and 0.73 (CI, 0.67 to 0.80), respectively.
Residual confounding and lack of clinical frailty assessment.
For older adults with AF, apixaban was associated with lower rates of adverse events across all frailty levels. Dabigatran and rivaroxaban were associated with lower event rates only among nonfrail patients.
National Institute on Aging.
在患有心房颤动（AF）的老年人中，不同程度的虚弱对口服抗凝剂的选择的作用尚不清楚。
通过虚弱程度检查比较直接口服抗凝剂（DOACs）与华法林的治疗结果。
2010 年至 2017 年期间，对 Medicare 数据进行了 1：1 的倾向评分匹配分析。
社区。
使用达比加群、利伐沙班、阿哌沙班或华法林的 Medicare 受益人群患有 AF。
通过基于索赔的虚弱指数定义的虚弱程度，计算死亡、缺血性中风或主要出血的复合终点。
在达比加群-华法林队列（n=158730；中位随访时间 72 天）中，达比加群和华法林的起始者的每 1000 人年的事件发生率分别为 63.5 和 65.6（风险比[HR]，0.98[95%CI，0.92 至 1.05]；率差[RD]，-2.2[CI，-6.5 至 2.1]）。对于非虚弱、虚弱前期和虚弱的患者，HR 分别为 0.81（CI，0.68 至 0.97）、0.98（CI，0.90 至 1.08）和 1.09（CI，0.96 至 1.23）。在利伐沙班-华法林队列（n=275944；中位随访时间 82 天）中，利伐沙班和华法林的起始者的每 1000 人年的事件发生率分别为 77.8 和 83.7（HR，0.98[CI，0.94 至 1.02]；RD，-5.9[CI，-9.4 至-2.4]）。对于非虚弱、虚弱前期和虚弱的患者，HR 分别为 0.88（CI，0.77 至 0.99）、1.04（CI，0.98 至 1.10）和 0.96（CI，0.89 至 1.04）。在阿哌沙班-华法林队列（n=218738；中位随访时间 84 天）中，阿哌沙班和华法林的起始者的每 1000 人年的事件发生率分别为 60.1 和 92.3（HR，0.68[CI，0.65 至 0.72]；RD，-32.2[CI，-36.1 至-28.3]）。对于非虚弱、虚弱前期和虚弱的患者，HR 分别为 0.61（CI，0.52 至 0.71）、0.66（CI，0.61 至 0.70）和 0.73（CI，0.67 至 0.80）。
残留混杂因素和缺乏临床虚弱评估。
对于患有 AF 的老年人，阿哌沙班在所有虚弱水平的不良事件发生率均较低。达比加群和利伐沙班仅在非虚弱患者中与较低的事件发生率相关。
美国国家老龄化研究所。
