Frailty and Clinical Outcomes of Direct Oral Anticoagulants Versus Warfarin in Older Adults With Atrial Fibrillation : A Cohort Study.
Frailty and Clinical Outcomes of Direct Oral Anticoagulants Versus Warfarin in Older Adults With Atrial Fibrillation : A Cohort Study.
复制标题
直接口服抗凝剂与华法林治疗老年房颤患者的虚弱和临床结果：一项队列研究。
DOI：
10.7326/m20-7141
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发表时间：
2021-09
影响因子：
39.2
通讯作者：
Schneeweiss S
中科院分区：
文献类型：
--
作者：
Kim DH;Pawar A;Gagne JJ;Bessette LG;Lee H;Glynn RJ;Schneeweiss S
不同程度的虚弱在选择口服抗凝剂治疗老年房颤（AF）患者中的作用尚不清楚。按照虚弱程度检查直接口服抗凝剂（DOAC）与华法林的结局，对Medicare数据进行1：1倾向评分匹配分析，2010-2017年开始达比加群、利伐沙班、阿哌沙班或华法林治疗的AF社区Medicare受益人。达比加群-华法林队列中，按照基于索赔的虚弱指数定义的虚弱程度，死亡、缺血性卒中或大出血的复合终点（n= 158 712;中位随访时间为72天），事件发生率达比加群酯使用者为63.5人/年，华法林使用者为65.6人/年（风险比[HR]，0.98 [95% CI：0.92，1.05];率差[RD]，-2.2 [-6.5，2.1]）。对于非虚弱、虚弱前和虚弱组，HR分别为0.81（0.68，0.97）、0.98（0.90，1.08）和1.09（0.96，1.23）。在利伐沙班-华法林队列（n= 275，944;中位随访时间，82天）中，利伐沙班启动者的事件发生率（每1，000人-年）为77.8，华法林启动者为83.7（HR，0.98 [0.94-1.02]; RD，-3.9 [-10.3，2.4]）。对于非虚弱、虚弱前和虚弱组，HR分别为0.88（0.77，0.99）、1.04（0.98，1.10）和0.96（0.89，1.04）。在阿哌沙班-华法林队列（n= 218，738;中位随访时间，84天）中，阿哌沙班启动者的事件发生率（每1，000人-年）为60.1，华法林启动者为92.3（HR，0.68 [0.65，0.72]; RD，-32.2 [-36.1，-28.3]）。对于非虚弱、虚弱前和虚弱组，HR分别为0.61（0.52，0.71）、0.66（0.61，0.70）和0.73（0.67，0.80）。剩余混杂因素，缺乏临床虚弱评估对于AF老年人，阿哌沙班与所有虚弱水平的不良事件发生率较低相关。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。国家老龄化研究所
The role of differing levels of frailty in choice of oral anticoagulants for older adults with atrial fibrillation (AF) remains unclear. To examine the outcomes of direct oral anticoagulants (DOAC) versus warfarin by frailty levels 1:1 propensity score-matched analysis of Medicare data, 2010-2017 Community Medicare beneficiaries with AF who initiated dabigatran, rivaroxaban, apixaban, or warfarin Composite endpoint of death, ischemic stroke, or major bleeding by frailty levels, defined by a claims-based frailty index In the dabigatran-warfarin cohort (n=158,712; median follow-up, 72 days), the event rate (per 1,000 person-years) was 63.5 for dabigatran-initiators and 65.6 for warfarin-initiators (hazard ratio [HR], 0.98 [95% CI: 0.92, 1.05]; rate difference [RD], −2.2 [−6.5, 2.1]). For non-frail, pre-frail, and frail groups, HRs were 0.81 (0.68, 0.97), 0.98 (0.90, 1.08), and 1.09 (0.96, 1.23), respectively. In the rivaroxaban-warfarin cohort (n=275,944; median follow-up, 82 days), the event rate (per 1,000 person-years) was 77.8 for rivaroxaban-initiators and 83.7 for warfarin-initiators (HR, 0.98 [0.94-1.02]; RD, −3.9 [−10.3, 2.4]). For non-frail, pre-frail, and frail groups, HRs were 0.88 (0.77, 0.99), 1.04 (0.98, 1.10), and 0.96 (0.89, 1.04), respectively. In the apixaban-warfarin cohort (n=218,738; median follow-up, 84 days), the event rate (per 1,000 person-years) was 60.1 for apixaban-initiators and 92.3 for warfarin-initiators (HR, 0.68 [0.65, 0.72]; RD, −32.2 [−36.1, −28.3]). For non-frail, pre-frail, and frail groups, HRs were 0.61 (0.52, 0.71), 0.66 (0.61, 0.70), and 0.73 (0.67, 0.80), respectively. Residual confounding, 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 non-frail patients. National Institute on Aging