Oral Anticoagulants and Antiplatelet Agents in Patients With Atrial Fibrillation and Concomitant Critical Limb Ischemia: A Nationwide Cohort Study |
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| Authors: | Hsin-Fu Lee Yi-Hsin Chan Pei-Ru Li Jia-Rou Liu Tze-Fan Chao Lung-Sheng Wu Shang-Hung Chang Yung-Hsin Yeh Chi-Tai Kuo Lai-Chu See Gregory Y.H. Lip |
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| Affiliation: | 1. Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan;2. College of Medicine, Chang Gung University, Taoyuan, Taiwan;3. Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan;4. Division of Cardiology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), Taipei, Taiwan;5. Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan;6. Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, Taiwan;7. Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan;8. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan;9. Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan, Taiwan;10. Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan;11. Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan;12. Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom;1. Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada;2. Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada;3. Safety Program Development Branch, Ministry of Transportation of Ontario, Toronto, Ontario, Canada;4. Queen’s University and Kingston Health Sciences Centre, Kingston, Ontario, Canada;5. Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, Health Research Innovation Centre, Calgary, Alberta, Canada;6. St Michael’s Hospital, Toronto, Ontario, Canada;7. Société de l’assurance Automobile du Québec, Québec, Québec, Canada;8. Department of Medicine, McMaster University, Hamilton General Hospital, Hamilton, Ontario, Canada;9. Division of Cardiology, Walter C. MacKenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada;10. Ottawa Hospital Research Institute, Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada;11. Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada;12. Heart Rhythm Vancouver, Division of Cardiology, Department of Medicine, Gordon & Leslie Diamond Health Care Centre, University of British Columbia, Vancouver, British Columbia, Canada;1. The John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA;2. Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois, USA;3. School of Kinesiology and Health Sciences, York University and KITE-Toronto Rehabilitation Institute, University of Health Network, University of Toronto, Toronto, Ontario, Canada;1. Montreal Heart Institute, Université de Montréal, Montreal, Québec, Canada;2. Duke Clinical Research Institute, Durham, North Carolina, USA;3. Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA;4. Duke-Margolis Center for Health Policy, Durham, North Carolina, USA;5. Sorbonne University, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Paris, France;1. Institute of Health Economics, Edmonton, Alberta, Canada;2. Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada;3. Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada |
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| Abstract: | BackgroundEvidence of clinical outcomes for oral anticoagulants and antiplatelet treatment (APT) in patients with atrial fibrillation (AF) and critical limb ischemia (CLI) is very limited.MethodsIn this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, 1223 patients with AF and CLI taking direct-acting oral coagulants (DOACs), warfarin, or APT were identified from June 1, 2012, to December 31, 2017. We used propensity score stabilized weighting (PSSW) to balance covariates across study groups.ResultsAfter PSSW, DOAC (n = 446) was associated with lower risks of ischemic stroke/systemic embolism (IS/SE), all major adverse limb events, and all major bleeding events compared with warfarin (n = 237). DOAC was associated with lower risks of IS/SE, acute myocardial infarction (AMI), and all major adverse limb events and a comparable risk of major bleeding events compared with APT (n = 540). DOAC has a lower risk of composite net-clinical-benefit outcome (IS/SE, AMI, all major adverse limb events, plus all major bleeding events) compared with warfarin (hazard ratio [HR]: 0.48; 95% confidence interval [CI]: 0.35-0.65; P < 0.0001) or APT (HR: 0.44; 95% CI: 0.34-0.56; P < 0.0001). The composite net-clinical-benefit outcome was comparable for warfarin vs APT. The reduced risk of net-clinical-benefit outcome for DOAC vs warfarin or APT persisted in high subgroups including age > 75 years, presence of diabetes mellitus, or chronic kidney disease.ConclusionsDOAC was associated with a significantly lower risk of composite net-clinical-benefit outcome than either warfarin or APT in patients with AF and concomitant CLI. Further prospective study is necessary to validate the findings in the future. |
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