Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin Among Adults With Cancer and Atrial Fibrillation.
Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin Among Adults With Cancer and Atrial Fibrillation.
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DOI：
10.1161/circoutcomes.122.008951
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发表时间：
2022-12
影响因子：
6.9
通讯作者：
Segal, Jodi B.
中科院分区：
文献类型：
--
作者：
Mehta, Hemalkumar B.;An, Huijun;Ardeshirrouhanifard, Shirin;Raji, Mukaila A.;Alexander, G. Caleb;Segal, Jodi B.
关键词：
虽然临床指南建议使用直接作用的口服抗凝剂(DOAC)而不是华法林来治疗孤立的非瓣膜性心房颤动(NVAF)，但对于癌症患者的NVAF治疗指南没有任何说明，这反映了这种情况下证据的匮乏。我们量化了患有癌症和NVAF的老年患者发生缺血性中风或全身血栓和大出血的相对风险(主要结果)，以及各种原因和心血管死亡(次要结果)，比较了DOAC和华法林。这项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，并链接了2010至2016年的美国医疗保险数据，包括新启动DOAC或华法林的被诊断患有癌症和NVAF的个人。我们使用逆处理概率加权(IPTW)来控制混杂。我们对主要结果和心血管死亡采用竞争风险回归，对全因死亡采用COX比例风险回归。在队列中的7675人中，4244人(55.3%)服用DOAC，3431人(44.7%)服用华法林。在IPTW分析中，DOAC和华法林使用者之间在缺血性中风或系统性栓塞的风险(每100人年1.24比1.19事件，调整后的风险比[AHR]1.41，95%可信区间[CI]0.92-2.14)、重大出血(每100人年3.08比4.49事件，AHR 0.90，CI 0.70-1.17)以及心血管死亡(1.88比3.14每100人年，AHR 0.82，Ci 0.59-0.1.13)。与华法林使用者相比，DOAC使用者的全因死亡风险(7.09比13.3每100人年，AHR 0.81，CI 0.69-0.94)显著降低。患有癌症和房颤的老年人暴露在DOAC中，与暴露于华法林的人相比，中风、全身血栓和大出血的风险相似。与华法林相比，DOAC的使用与心血管死亡的风险相似，全因死亡的风险更低。
While clinical guidelines recommend direct-acting oral anticoagulants (DOAC) over warfarin to treat isolated non-valvular atrial fibrillation (NVAF), guidelines are silent regarding NVAF 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 NVAF comparing DOACs and warfarin. This retrospective cohort study used Surveillance, Epidemiology, and End Results cancer registry and linked US Medicare data from 2010 to 2016, and included individuals diagnosed with cancer and NVAF who newly initiated DOAC or warfarin. We used inverse probability of treatment weighting (IPTW) to control confounding. We used competing risk regression for primary outcomes and cardiovascular death, and Cox proportional hazard regression for all-cause death. Among 7,675 individuals included in the cohort, 4,244 (55.3%) received DOACs and 3,431 (44.7%) warfarin. In the IPTW analysis, there was no statistically significant difference among DOAC and warfarin users in the risk of ischemic stroke or systemic embolism (1.24 vs. 1.19 events per 100 person-years, adjusted hazard ratio [aHR] 1.41, 95% confidence intervals [CI] 0.92-2.14), major bleeding (3.08 vs. 4.49 events per 100 person-years, aHR 0.90, CI 0.70-1.17), and cardiovascular death (1.88 vs. 3.14 per 100 person-years, aHR 0.82, CI 0.59-0.1.13). DOAC users had significantly lower risk of all-cause death (7.09 vs. 13.3 per 100 person-years, aHR 0.81, CI 0.69-0.94) compared to warfarin users. Older adults with cancer and AF 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.
影响因子：
5.7
作者：
Gross, Cary P.;Galusha, Deron H.;Krumholz, Harlan M.
通讯作者：
Krumholz, Harlan M.