Dawwas Ghadeer K, Lewis James D, Cuker Adam
Department of Medicine, Division of Epidemiology Vanderbilt University School of Medicine Nashville TN.
Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine University of Pennsylvania Philadelphia PA.
J Am Heart Assoc. 2025 Feb 18;14(4):e035478. doi: 10.1161/JAHA.124.035478. Epub 2025 Feb 14.
Despite proven efficacy and safety of direct oral anticoagulants (DOACs) over warfarin in patients with atrial fibrillation (AF), data on patients with AF and valvular heart disease remain scarce. We aimed to evaluate the DOACs compared with warfarin among patients with AF and valvular heart disease.
We conducted a retrospective cohort study of patients ≥18 years of age, who had AF and valvular heart disease, and were new users of DOACs or warfarin. The primary effectiveness outcomes were ischemic stroke or systemic embolism, and bleeding for safety. We used Cox proportional-hazards regression after propensity score matching to estimate hazard ratios (HRs) and 95% CIs. In the matched cohort, DOAC use (versus warfarin) was associated with a lower rate of ischemic stroke or systemic embolism (HR, 0.70 [95% CI, 0.61-0.81]) and bleeding (HR, 0.72 [95% CI, 0.65-0.80]). We found a lower rate of ischemic stroke or systemic embolism with rivaroxaban (HR, 0.74 [95% CI, 0.62-0.89]) and apixaban (HR, 0.62 [95% CI, 0.52-0.74]) but not dabigatran (HR, 0.89 [95% CI, 0.63-1.26]). We found a lower rate of bleeding with rivaroxaban (HR, 0.84 [95% CI, 0.74-0.95]), apixaban (HR, 0.60 [95% CI, 0.53-0.68]), dabigatran (HR, 0.75 [95% CI, 0.58-0.97]), and edoxaban (HR, 0.21 [95% CI, 0.05-0.83]). We were unable to obtain estimates for the effectiveness outcome with edoxaban due to the small number of events.
In this study of patients with AF and valvular heart disease, DOAC treatment was associated with a lower risk of ischemic stroke or systemic embolism and bleeding compared with warfarin.
尽管直接口服抗凝剂（DOACs）在心房颤动（AF）患者中已被证明比华法林更有效且更安全，但关于AF合并心脏瓣膜病患者的数据仍然稀少。我们旨在评估AF合并心脏瓣膜病患者中DOACs与华法林相比的效果。
我们对年龄≥18岁、患有AF和心脏瓣膜病且新使用DOACs或华法林的患者进行了一项回顾性队列研究。主要有效性结局为缺血性卒中或全身性栓塞，安全性结局为出血。我们在倾向评分匹配后使用Cox比例风险回归来估计风险比（HRs）和95%置信区间（CIs）。在匹配队列中，使用DOACs（与华法林相比）与较低的缺血性卒中或全身性栓塞发生率（HR，0.70 [95% CI，0.61 - 0.81]）和出血发生率（HR，0.72 [95% CI，0.65 - 0.80]）相关。我们发现利伐沙班（HR，0.74 [95% CI，0.62 - 0.89]）和阿哌沙班（HR，0.62 [95% CI，0.52 - 0.74]）的缺血性卒中或全身性栓塞发生率较低，但达比加群（HR，0.89 [95% CI，0.63 - 1.26]）并非如此。我们发现利伐沙班（HR，0.84 [95% CI，0.74 - 0.95]）、阿哌沙班（HR，0.60 [95% CI，0.53 - 0.68]）、达比加群（HR，0.75 [95% CI，0.58 - 0.97]）和依度沙班（HR，0.21 [95% CI，0.05 - 0.83]）的出血发生率较低。由于事件数量较少，我们无法获得依度沙班有效性结局的估计值。
在这项针对AF合并心脏瓣膜病患者的研究中，与华法林相比，DOAC治疗与较低的缺血性卒中或全身性栓塞风险和出血风险相关。
