Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
JAMA Netw Open. 2023 Apr 3;6(4):e239973. doi: 10.1001/jamanetworkopen.2023.9973.
The temporal trend in adverse events regarding stroke prevention for nonvalvular atrial fibrillation (NVAF) in the direct oral anticoagulant (DOAC) era was rarely investigated comprehensively, especially taking into account potential changes in patient characteristics and anticoagulation treatment.
To investigate time trends in patient characteristics, anticoagulation treatment, and prognosis of patients with incident NVAF in the Netherlands.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed patients with incident NVAF initially recognized within a hospitalization between 2014 and 2018, using data from Statistics Netherlands. Participants were followed-up for 1 year from the hospital admission at which the incident NVAF diagnosis was made or until death, whichever occurred first. Data were analyzed from January 15, 2021, to March 8, 2023.
Calendar year of the incident NVAF diagnosis, according to which the participants were categorized into 5 cohorts.
Outcomes of interest were baseline patient characteristics, anticoagulation treatment, and occurrence of ischemic stroke or major bleeding within the 1-year follow-up after incident NVAF.
Between 2014 and 2018, 301 301 patients (mean [SD] age, 74.2 [11.9] years; 169 748 [56.3%] male patients) experienced incident NVAF in the Netherlands, each of whom was categorized into 1 of 5 cohorts by calendar year. Baseline patient characteristics were broadly the same between cohorts with a mean (SD) CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65 to 74 years, and sex category [female]) score of 2.9 (1.7). The median (IQR) proportion of days covered by OACs (ie, vitamin K antagonists or DOACs) within the 1-year follow-up increased from 56.99% (0%-86.30%) to 75.62% (0%-94.52%), and DOACs increased from 5102 patients (13.5%) to 32 314 patients (72.0%) among those who received OACs, gradually replacing VKAs as the first choice of OACs. Over the course of the study, there were statistically significant decreases in the 1-year cumulative incidence of ischemic stroke (from 1.63% [95% CI, 1.52%-1.73%] to 1.39% [95% CI, 1.30%-1.48%) and major bleeding (from 2.50% [95% CI, 2.37%-2.63%] to 2.07% [95% CI, 1.96%-2.19%]), and the association was consistent after adjusting for baseline patient characteristics and excluding those with preexisting chronic anticoagulation.
This cohort study of patients with incident NVAF diagnosed between 2014 and 2018 in the Netherlands found similar baseline characteristics, increased OAC use with DOACs being favored over time, and improved 1-year prognosis. Comorbidity burden, potential underuse of anticoagulation medications, and specific subgroups of patients with NVAF remain directions for future investigations and further improvement.
在直接口服抗凝剂（DOAC）时代，关于非瓣膜性心房颤动（NVAF）卒中预防的不良事件的时间趋势很少被全面研究，尤其是考虑到患者特征和抗凝治疗的潜在变化。
调查荷兰 NVAF 患者的患者特征、抗凝治疗和预后的时间趋势。
设计、设置和参与者：本回顾性队列研究评估了 2014 年至 2018 年期间住院期间首次确诊为 NVAF 的患者的特征，使用了荷兰统计局的数据。参与者在 NVAF 确诊入院后的 1 年内进行随访，以出院或死亡为随访终点，以先发生者为准。数据于 2021 年 1 月 15 日至 2023 年 3 月 8 日进行分析。
NVAF 确诊的年份，参与者据此分为 5 个队列。
感兴趣的结局是基线患者特征、抗凝治疗以及 NVAF 确诊后 1 年内发生缺血性卒中和大出血。
2014 年至 2018 年期间，荷兰有 301301 例患者（平均[SD]年龄 74.2[11.9]岁；169748[56.3%]男性患者）发生 NVAF，每位患者根据确诊年份被分为 1 个队列。各队列之间的基线患者特征大致相同，CHA2DS2-VASc（充血性心力衰竭、高血压、年龄≥75 岁[翻倍]、糖尿病、卒中[翻倍]、血管疾病、65 岁至 74 岁和性别类别[女性]）评分平均（SD）为 2.9（1.7）。1 年内接受 OAC 治疗的患者中 OAC 覆盖天数（即维生素 K 拮抗剂或 DOAC）的中位数（IQR）从 56.99%（0%-86.30%）增加到 75.62%（0%-94.52%），DOAC 从 5102 例（13.5%）增加到 32314 例（72.0%），作为 OAC 的首选药物，逐渐取代 VKAs。在研究过程中，缺血性卒中和大出血的 1 年累积发生率均呈统计学显著下降（从 1.63%（95%CI，1.52%-1.73%）降至 1.39%（95%CI，1.30%-1.48%）和 2.50%（95%CI，2.37%-2.63%）降至 2.07%（95%CI，1.96%-2.19%）），且调整基线患者特征和排除存在慢性抗凝治疗的患者后，相关性仍一致。
本研究对 2014 年至 2018 年期间荷兰确诊的 NVAF 患者进行了队列研究，发现基线特征相似，随着时间的推移，OAC 使用率增加，DOAC 受到青睐，1 年预后改善。合并症负担、抗凝药物潜在使用不足以及 NVAF 的特定亚组仍然是未来研究和进一步改善的方向。
