Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan.
Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
J Am Geriatr Soc. 2022 Jul;70(7):2029-2039. doi: 10.1111/jgs.17770. Epub 2022 Apr 9.
Direct oral anticoagulants (DOACs) have been used for both primary and secondary prevention of cerebral infarction in older patients with atrial fibrillation (AF). However, whether DOACs are more effective and safer than warfarin for secondary prevention of cerebral infarction in older patients with AF remains unclear.
Using the Japanese Diagnosis Procedure Combination database, we identified patients with AF who were hospitalized for cerebral infarction from January 1, 2015 to March 31, 2019 and were aged ≥75 years at admission. We performed propensity score-stabilized inverse probability of treatment weighting analyses to balance measured confounders between patients with AF receiving DOACs and those receiving warfarin after discharge. The primary outcomes were 365-day readmission for (a) benefit: cerebral infarction or (b) harm: bleeding events after discharge. The secondary outcomes were 365-day readmission for intracranial bleeding or gastrointestinal bleeding after discharge as well as all-cause death during readmission. Using a Fine-Gray model, we compared the subdistribution hazard ratios (SHRs) of readmission between the DOAC group and warfarin group.
We identified 101,389 eligible patients, including 80,726 patients receiving DOACs and 20,663 patients receiving warfarin. After the propensity score-stabilized inverse probability of treatment weighting, the adjusted SHRs of readmission (95% confidence interval [CI]) for cerebral infarction, bleeding events, and intracranial bleeding in the DOAC group as compared with the warfarin group were 0.76 (0.71-0.81), 0.78 (0.68-0.90), and 0.69 (0.57-0.82), respectively. There was no significant difference in readmission for gastrointestinal bleeding (SHR, 1.01; 95% CI, 0.72-1.41) between the DOAC and warfarin groups.
In this retrospective nationwide study, DOACs were more effective and safer than warfarin for preventing reinfarction and bleeding events in patients with AF aged ≥75 years who have a history of cerebral infarction.
直接口服抗凝剂（DOACs）已被用于老年房颤（AF）患者的脑梗死的一级和二级预防。然而，DOACs 用于老年 AF 患者的脑梗死二级预防是否比华法林更有效和更安全仍不清楚。
使用日本诊断程序组合数据库，我们确定了 2015 年 1 月 1 日至 2019 年 3 月 31 日因脑梗死住院且入院时年龄≥75 岁的 AF 患者。我们进行了倾向评分稳定的逆概率治疗加权分析，以平衡出院后接受 DOAC 治疗和华法林治疗的 AF 患者之间的测量混杂因素。主要结局是 365 天内因（a）获益：脑梗死或（b）危害：出血事件的再入院率。次要结局是 365 天内颅内出血或胃肠道出血的再入院率以及再入院期间的全因死亡率。使用 Fine-Gray 模型，我们比较了 DOAC 组和华法林组的再入院亚分布风险比（SHR）。
我们确定了 101389 名符合条件的患者，其中 80726 名患者接受 DOAC 治疗，20663 名患者接受华法林治疗。在倾向评分稳定的逆概率治疗加权后，与华法林组相比，DOAC 组再入院（95%置信区间[CI]）的调整 SHRs 为脑梗死、出血事件和颅内出血分别为 0.76（0.71-0.81）、0.78（0.68-0.90）和 0.69（0.57-0.82）。DOAC 组和华法林组之间再入院的胃肠道出血（SHR，1.01；95%CI，0.72-1.41）无显著差异。
在这项回顾性全国性研究中，DOAC 用于预防有脑梗死病史的≥75 岁 AF 患者再梗死和出血事件的效果优于华法林，且更安全。
