Background

Direct oral anticoagulants (DOACs) are at least as effective as vitamin K antagonists (VKAs) for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). DOACs are associated with less intracranial hemorrhage and are easier to administer and therfore have become standard of care for stroke prevention in NVAF patients. Nevertheless, many eligible patients still receive no anticoagulation. The effect on overall mortality in routine practice of DOAC therapy compared to no anticoagulation in NVAF patients is unknown.

Methods

We identified all newly diagnosed, anticoagulant naive NVAF patients eligible for DOAC therapy from 2011 to 2016 in Clalit Health Services, the largest HMO in Israel. We created a matched cohort, using 1:1 propensity score matching of DOAC -treated versus non-anticoagulant treated NVAF patients. The primary outcome was overall mortality rate in the two cohorts. Secondary outcomes were rates of stroke, major cardiac and bleeding events.

Results

28,195 newly diagnosed CHADS2 ≥2 NVAF patients were identified. Of these 8 298 received a DOAC and 10 603 received no anticaogulation. The remainder received a VKA and were not included in this study. Patients recieving DOAC therapy were younger (77.4 vs 78.0 years), had a higher socioeconomic status (5.6 vs. 5.3), had a female predominance (53.7% vs 52.0%), had a higher BMI (29.6 vs 28.3) and had a greater prevalance of accompanying cardiovascular morbidities namely congestive heart failure (CHF) (29% vs 27%) and stroke (33% vs 30%) (P<0.001 for all variables) . 5,657 patients who received DOAC therapy were matched with 5,657 patients not receiving an anticoagulant using propensity score matching. DOAC therapy was associated with significantly lower risk for death (hazard ratio 0.66, 95% CI 0.60-0.71, P<0.001). Rates of stroke and major cardiac were significantly lower in the DOAC-treated than in the non-anticoagulated patients. DOAC therapy was associated with a significant survival benefit across all patient subgroups.

Conclusions

In this cohort of newly diagnosed NVAF patients treated in routine clinical practice, DOAC therapy was associated with a lower risk for death compared to no oral anticoagulation. Our findings provide further evidence for the importance of DOAC therapy in NVAF patients.

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Disclosures

No relevant conflicts of interest to declare.

Topics:
atrial fibrillation, direct oral anticoagulants, nonvalvular atrial fibrillation, anticoagulants, anticoagulation, cerebrovascular accident, ischemic stroke, vitamin k antagonists, congestive heart failure, risk reduction

Author notes

*

Asterisk with author names denotes non-ASH members.

© 2018 by The American Society of Hematology
2018
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