title: Long-Term Population-Based Cerebral Ischemic Event and Cognitive Outcomes of Direct Oral Anticoagulants Compared With Warfarin Among Long-term Anticoagulated Patients for Atrial Fibrillation.
abstract: Direct oral anticoagulants (DOACs) have been used in clinical practice in the United States for the last 4 to 6 years. Although DOACs may be an attractive alternative to warfarin in many patients, long-term outcomes of use of these medications are unknown. We performed a propensity-matched analysis to report patient important outcomes of death, stroke/transient ischemic attack (TIA), bleeding, major bleeding, and dementia in patients taking a DOAC or warfarin. Patients receiving long-term anticoagulation from June 2010 to December 2014 for thromboembolism prevention with either warfarin or a DOAC were matched 1:1 by index date and propensity score. Multivariable Cox hazard regression was performed to determine the risk of death, stroke/TIA, major bleed, and dementia by the anticoagulant therapy received. A total of 5,254 patients were studied (2,627 per group). Average age was 72.4 ± 10.9 years, and 59.0% were men. Most patients were receiving long-term anticoagulation for AF management (warfarin: 96.5% vs DOAC: 92.7%, p <0.0001). Rivaroxaban (55.3%) was the most commonly used DOAC, followed by apixaban (22.5%) and dabigatran (22.2%). The use of DOACs compared with warfarin was associated with a reduced risk of long-term adverse outcomes: death (p = 0.09), stroke/TIA (p <0.0001), major bleed (p <0.0001), and bleed (p = 0.14). No significant outcome variance was noted in DOAC-type comparison. In the AF multivariable model patients taking DOAC were 43% less likely to develop stroke/TIA/dementia (hazard ratio 0.57 [CI 0.17, 1.97], p = 0.38) than those taking warfarin. Our community-based results suggest better long-term efficacy and safety of DOACs compared with warfarin. DOAC use was associated with a lower risk of cerebral ischemic events and new-onset dementia.
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: Victoria
authors.initials: V
authors.lastname: Jacobs
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: Heidi T
authors.initials: HT
authors.lastname: May
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: Tami L
authors.initials: TL
authors.lastname: Bair
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: Brian G
authors.initials: BG
authors.lastname: Crandall
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Cutler
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: John D
authors.initials: JD
authors.lastname: Day
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: Charles
authors.initials: C
authors.lastname: Mallender
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Osborn
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: Scott M
authors.initials: SM
authors.lastname: Stevens
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: J Peter
authors.initials: JP
authors.lastname: Weiss
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah.
authors.forename: Scott C
authors.initials: SC
authors.lastname: Woller
authors.affiliation: Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah. Electronic address: thomas.bunch@imail.org.
authors.forename: T Jared
authors.initials: TJ
authors.lastname: Bunch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D000991:Antithrombins / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D000069604:Dabigatran / Q000627:therapeutic use; D003704:Dementia / Q000453:epidemiology; D065427:Factor Xa Inhibitors / Q000627:therapeutic use; D005260:Female; D006470:Hemorrhage / Q000453:epidemiology; D006801:Humans; D002546:Ischemic Attack, Transient / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D009026:Mortality; D015999:Multivariate Analysis; D057216:Propensity Score; D016016:Proportional Hazards Models; D011720:Pyrazoles / Q000627:therapeutic use; D011728:Pyridones / Q000627:therapeutic use; D000069552:Rivaroxaban / Q000627:therapeutic use; D020521:Stroke / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D000991:Antithrombins; D065427:Factor Xa Inhibitors; D011720:Pyrazoles; D011728:Pyridones; C522181:apixaban; D014859:Warfarin; D000069552:Rivaroxaban; D000069604:Dabigatran