Vitamin K Antagonists and Direct Oral Anticoagulants in Nonagenarian Patients With Atrial Fibrillation |
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| Affiliation: | 1. Department of Cardiology, University Hospital Alvaro Cunqueiro, Vigo, Spain;2. Department of Cardiology, University Hospital of Leon, Spain;3. Department of Cardiology, University Hospital Juan Ramón Jiménez, Huelva, Spain;4. Department of Geriatric Medicine, University Hospital Alvaro Cunqueiro, Vigo, Spain;5. Directive Staff, University Hospital, Orense, Spain;6. Hospital Admission Department, University Hospital Alvaro Cunqueiro, Vigo, Spain;1. US Department of Veterans Affairs Medical Center, Providence, RI;2. Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI;3. Portland State University, Portland, OR;1. Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu, China;2. The Second Clinical Medical School, Nanjing University of Chinese Medicine, Jiangsu, China;3. The Teaching and Research Department of Statistics, Nanjing Medical University, Jiangsu, China;4. Rehabilitation Center, The Second Affiliated Hospital of HaiNan Medical University, Hainan, China;5. The Rehabilitation Department, The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Henan, China;6. The Acupuncture Rehabilitation Department, Jiangsu Province Hospital of Traditional Chinese Medicine, Jiangsu, China;7. Rehabilitation Center, The Second Affiliated Hospital of Heilongjiang University of Chinese Medicine, Heilongjiang, China;8. The Rehabilitation Department, Guangdong Provincial Traditional Chinese Medicine Hospital, Guangdong, China;9. The Rehabilitation Department, Tongji Medical College Huazhong University of Science & Technology, Hubei, China;10. The Neurological Rehabilitation Department, Shanghai University of Traditional Chinese Medicine, Shanghai, China;11. Rehabilitation Center, Xuzhou Central Hospital, Jiangsu, China;12. The Rehabilitation Department, The Affiliated Hospital of Xuzhou Medical University, Jiangsu, China;13. The Rehabilitation Department, Tianjin Medical University General Hospital, Tianjin, China;14. The Neurology Department, Nanjing Hospital of Traditional Chinese Medicine, Jiangsu, China;15. The Rehabilitation Department, Hubei Provincial Hospital of Integrated Chinese & Western Medicine, Hubei, China;p. The Rehabilitation Department, Dongguan Kanghua Hospital, Guangdong, China;q. School of Basic Medical Sciences, Nanjing Medical University, Jiangsu, China;1. Unit for Research on Aging Society, Department of Sociology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland;2. Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland;3. Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands;4. National Institute for Health and Welfare, Helsinki, Finland;5. Division of Health Research, Lancaster University, Lancaster, UK;6. Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy;7. Università Cattolica del Sacro Cuore, Rome, Italy;8. Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands;9. Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium;10. Department of Family Medicine and Chronic Care, End-of- Life Care Research Group, Vrije Universiteit Brussel (VUB) and Ghent University, Brussels, Belgium;1. Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Belgium;2. Institute of Health and Society, Université Catholique de Louvain, Belgium;3. Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom |
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| Abstract: | ObjectivesNonagenarian patients are underrepresented in clinical trials that have evaluated oral anticoagulation in patients with atrial fibrillation (AF). The aim of this study was to assess the pronostic impact of oral anticoagulation in patients with AF age ≥90 years.DesignRetrospective multicenter study of nonagenarian patients with AF.Setting and participantsA total of 1750 nonagenarian inpatients and outpatients with nonvalvular AF between January 2013 and December 2018 in 3 Spanish health areas were studied.MethodsPatients were divided into 3 groups based on antithrombotic therapy: nonoral anticoagulants (30.5%), vitamin-K antagonists (VKAs; 28.6%), and direct oral anticoagulants (DOACs; 40.9%). During a mean follow-up of 23.6 ± 6.6 months, efficacy outcomes (death and embolic events) were evaluated using a Cox regression analysis and safety outcomes (bleeding requiring hospitalization) by competing-risk regression. Results were complemented with a propensity score matching analysis.ResultsDuring follow-up, 988 patients died (56.5%), 180 had embolic events (10.3%), and 186 had major bleeding (10.6%). After multivariable adjustment, DOACs were associated with a lower risk of death and embolic events than nonanticoagulation [hazard ratio (HR) 0.75, 95% confidence interval (CI)] 0.61‒0.92), but VKAs were not (HR 0.87, 95% CI 0.72‒1.05). These results were confirmed after propensity score matching analysis. For bleeding, both DOACs and VKAs proved to be associated with a higher risk (HR for DOAC 1.43; 95% CI 0.97‒2.13; HR for VKA 1.94; 95% CI 1.31‒2.88), although findings for DOACs were not statistically significant (P = .074). For intracranial hemorrhage (ICH), only VKAs—not DOACs—presented a higher risk of ICH (HR 4.43; 95% CI 1.48‒13.31).Conclusions and implicationsIn nonagenarian patients with AF, DOACs led to a reduction in mortality and embolic events in comparison with nonanticoagulation. This reduction was not observed with VKAs. Although both DOACs and VKAs increased the risk of bleeding, only VKAs were associated with higher ICH rates. |
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| Keywords: | Atrial fibrillation nonagenarian Vitamin K antagonist direct oral anticoagulants stroke major bleeding |
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