NOACs match warfarin for atrial fibrillation

By Laura Cowen

Real-world study data from Denmark show that non-vitamin K antagonist oral anticoagulants are effective alternatives to warfarin in patients with non-valvular atrial fibrillation in a routine care setting.

The novel oral anticoagulants (NOACs) dabigatran, rivaroxaban and apixaban were also associated with similar or lower rates of bleeding and death than warfarin among the 61,678 patients who were new users of oral anticoagulants and had no previous indication for valvular atrial fibrillation or venous thromboembolism.

The data, analysed by Torben Larsen (Aalborg University Hospital, Denmark) and colleagues, were collected from the Danish national prescription registry, the Danish national patient register, and the Danish civil registration system between August 2011 to October 2015.

As reported in The BMJ, Larsen found that NOAC prescribing rates differed according to patient characteristics. For example, dabigatran was more common than the three alternatives in younger patients with a lower risk of stroke and less renal impairment. And rivaroxaban and apixaban were more often used in patients with previous ischaemic stroke or systemic embolism.

"Our methodological approach accounted for such 'real world' selective prescribing through propensity weights", the authors note.

The analysis showed that, during the first year of treatment, the risk of ischaemic stroke did not differ significantly between the NOACs and warfarin.

However, for the combined endpoint of ischaemic stroke or systemic embolism, the weighted annual rate was significantly lower among the 7192 patients who received rivaroxaban 20 mg/day than among the 35,436 who received warfarin 2.5 mg/day, at 2.9% versus 3.3%. This was equivalent to a 17% risk reduction.

The weighted annual rate of any bleeding with rivaroxaban was similar to that with warfarin, at 4.8% and 4.7%, respectively.

By contrast, the 12,701 patients who received dabigatran 150 mg twice daily and the 6349 who received apixaban 5 mg twice daily had significantly lower weighted annual rates of bleeding, at 2.9% and 3.1% respectively, than those who received warfarin, which was equivalent to risk reductions of 39% and 37%, respectively.

Patients receiving dabigatran and apixaban also had significantly lower weighted all-cause mortality than those receiving warfarin, at 4.6% and 5.0%, respectively, versus 7.4%, whereas the rate was similar to that of warfarin in the patients receiving rivaroxaban (7.0%).

The risk of ischaemic stroke or systemic embolism in the patients who received dabigatran and apixaban was similar to that among the patients who received warfarin, however.

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BMJ 2016; 353: i3189


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