Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (H.B.M., H.A., S.A., G.C.A., J.B.S.).
Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (H.B.M., H.A., S.A., G.C.A., J.B.S.).
Circ Cardiovasc Qual Outcomes. 2022 Dec;15(12):e008951. doi: 10.1161/CIRCOUTCOMES.122.008951. Epub 2022 Dec 1.
While clinical guidelines recommend direct-acting oral anticoagulants (DOAC) over warfarin to treat isolated nonvalvular atrial fibrillation, guidelines are silent regarding nonvalvular atrial fibrillation treatment among individuals with cancer, reflecting the paucity of evidence in this setting. We quantified relative risk of ischemic stroke or systemic embolism and major bleeding (primary outcomes), and all-cause and cardiovascular death (secondary outcomes) among older individuals with cancer and nonvalvular atrial fibrillation comparing DOACs and warfarin.
This retrospective cohort study used Surveillance, Epidemiology, and End Results cancer registry and linked US Medicare data from 2010 through 2016, and included individuals diagnosed with cancer and nonvalvular atrial fibrillation who newly initiated DOAC or warfarin. We used inverse probability of treatment weighting to control confounding. We used competing risk regression for primary outcomes and cardiovascular death, and Cox proportional hazard regression for all-cause death.
Among 7675 individuals included in the cohort, 4244 (55.3%) received DOACs and 3431 (44.7%) warfarin. In the inverse probability of treatment weighting analysis, there was no statistically significant difference among DOAC and warfarin users in the risk of ischemic stroke or systemic embolism (1.24 versus 1.19 events per 100 person-years, adjusted hazard ratio 1.41 [95% CI, 0.92-2.14]), major bleeding (3.08 versus 4.49 events per 100 person-years, adjusted hazard ratio 0.90 [95% CI, 0.70-1.17]), and cardiovascular death (1.88 versus 3.14 per 100 person-years, adjusted hazard ratio 0.82 [95% CI, 0.59-0.1.13]). DOAC users had significantly lower risk of all-cause death (7.09 versus 13.3 per 100 person-years, adjusted hazard ratio 0.81 [95% CI, 0.69-0.94]) compared to warfarin users.
Older adults with cancer and atrial fibrillation exposed to DOACs had similar risks of stroke and systemic embolism and major bleeding as those exposed to warfarin. Relative to warfarin, DOAC use was associated with a similar risk of cardiovascular death and a lower risk of all-cause death.
虽然临床指南建议使用直接口服抗凝剂（DOAC）而非华法林治疗孤立性非瓣膜性心房颤动，但对于癌症患者的非瓣膜性心房颤动治疗，指南并未提及，这反映出该领域证据不足。我们比较了 DOAC 和华法林在老年癌症合并非瓣膜性心房颤动患者中的缺血性卒中或全身性栓塞和大出血（主要结局）以及全因和心血管死亡（次要结局）的相对风险。
本回顾性队列研究使用了监测、流行病学和最终结果癌症登记处和 2010 年至 2016 年美国医疗保险数据进行链接，纳入了新诊断为癌症和非瓣膜性心房颤动且开始使用 DOAC 或华法林的患者。我们使用逆概率治疗加权来控制混杂因素。我们使用竞争风险回归来分析主要结局和心血管死亡，使用 Cox 比例风险回归来分析全因死亡。
在纳入的 7675 名患者中，4244 名（55.3%）接受了 DOAC 治疗，3431 名（44.7%）接受了华法林治疗。在逆概率治疗加权分析中，DOAC 和华法林使用者的缺血性卒中或全身性栓塞风险无统计学差异（每 100 人年 1.24 与 1.19 例，调整后的危险比为 1.41[95%可信区间，0.92-2.14]）、大出血（每 100 人年 3.08 与 4.49 例，调整后的危险比为 0.90[95%可信区间，0.70-1.17]）和心血管死亡（每 100 人年 1.88 与 3.14 例，调整后的危险比为 0.82[95%可信区间，0.59-0.11.3]）。与华法林使用者相比，DOAC 使用者的全因死亡风险显著降低（每 100 人年 7.09 与 13.3 例，调整后的危险比为 0.81[95%可信区间，0.69-0.94]）。
接受 DOAC 治疗的老年癌症合并心房颤动患者的卒中、全身性栓塞和大出血风险与接受华法林治疗的患者相似。与华法林相比，DOAC 治疗的心血管死亡风险相似，全因死亡风险较低。
