Sex-Based Differences in Outcomes of Oral Anticoagulation in Patients With Atrial Fibrillation
Sex-Based Differences in Outcomes of Oral Anticoagulation in Patients With Atrial Fibrillation
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DOI：
10.1016/j.jacc.2018.04.066
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发表时间：
2018-07-17
影响因子：
24
通讯作者：
Chan, Esther W.
中科院分区：
文献类型：
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作者：
Law, Sharon W. Y.;Lau, Wallis C. Y.;Chan, Esther W.
背景：尽管接受华法林治疗，患有房颤的女性仍有较高的中风风险。目前尚不清楚接受直接口服抗凝剂(DOAC)治疗的女性是否有更好的临床结果，特别是考虑到华法林抗凝控制的质量。目的本研究比较了DOAC和华法林在抗凝控制分层的男性和女性中的有效性和安全性。对男性和女性分别进行倾向性评分匹配。进一步的分析是根据华法林使用者的抗凝控制情况对其进行分层。用COX回归分析比较不同性别患者发生缺血性卒中或全身性脑梗塞、颅内出血、消化道出血和全因死亡率的风险。与华法林相比，在女性中，DOAC的使用与较低的脑出血风险(风险比[HR]：0.16；95%可信区间[CI]：0.06至0.40)和全因死亡率(HR：0.55；95%CI：0.39至0.77)相关，但在男性中不相关。性交治疗只对脑出血有意义，与女性中抗凝控制良好的华法林使用者相比，DOAC组发生脑出血的风险显著降低(HR：0.13；95%CI：0.02~1.00)。在男女患者中，DOAC与华法林相比，发生缺血性卒中或全身性栓塞以及胃肠道出血的风险相当。结论DOAC仅与女性患者发生脑出血和全因死亡率降低有关，与抗凝控制良好的华法林使用者相比，女性发生脑出血的风险仍然较低。(C)2018年，由美国心脏病学院基金会提供。
BACKGROUND Women with atrial fibrillation are at a higher risk of stroke, despite treatment with warfarin. It is unclear if women treated with direct oral anticoagulants (DOACs) have better clinical outcomes, especially when considering the quality of anticoagulation control of warfarin.OBJECTIVES This study compared the effectiveness and safety outcomes of DOACs versus warfarin in men and women with stratifications for anticoagulation control.METHODS Patients newly diagnosed with atrial fibrillation and prescribed oral anticoagulants during 2010 to 2015 were identified using the Hong Kong clinical database. Propensity score matching was performed in men and women separately. Further analysis was conducted to stratify warfarin users according to their anticoagulation control. Cox regression was used to compare the risk of ischemic stroke or systemic embolism, intracranial hemorrhage (ICH), gastrointestinal bleeding, and all-cause mortality in the specific sex.RESULTS There were 4,972 men and 4,834 women successfully matched in our cohort. Compared with warfarin, DOAC use was associated with a lower risk of ICH (hazard ratio [HR]: 0.16; 95% confidence interval [CI]: 0.06 to 0.40) and allcause mortality (HR: 0.55; 95% CI: 0.39 to 0.77) in women but not in men. The treatment by sex interaction was significant for ICH only, and a significantly lower risk of ICH remained in the DOAC group when compared with warfarin users with good anticoagulation control (HR: 0.13; 95% CI: 0.02 to 1.00) among women only. The risks of ischemic stroke or systemic embolism and gastrointestinal bleeding with DOACs versus warfarin were comparable in both sexes.CONCLUSIONS DOACs were associated with a lower risk of ICH and all-cause mortality in women only, where the association of lower ICH risk remained when compared with warfarin users with good anticoagulation control. (C) 2018 by the American College of Cardiology Foundation.