Key result
Reduced-dose dabigatran and rivaroxaban were associated with lower risks of all-cause death (HR 0.59 and 0.61, respectively) compared to warfarin in adults aged ≥85 with atrial fibrillation.
Why the study?
Does reduced-dose dabigatran or rivaroxaban reduce mortality and adverse clinical outcomes compared to warfarin in adults aged 85 and older with atrial fibrillation?
Cohort (n=4,722)
Does reduced-dose dabigatran or rivaroxaban reduce mortality and adverse clinical outcomes compared to warfarin in adults aged 85 and older with atrial fibrillation?
Hazard Ratio: 0.59 (95% CI 0.45–0.77)
In very elderly patients (≥85 years) with atrial fibrillation, reduced-dose dabigatran and rivaroxaban are associated with lower all-cause and cardiovascular mortality compared to warfarin, with dabigatran also showing lower intracranial hemorrhage risk.
Reduced-dose NOACs were associated with lower mortality vs warfarin in AF patients ≥85; leaves open whether they should be preferred pending RCTs.
OBJECTIVES: To compare the effectiveness and safety of reduced-dose dabigatran, reduced-dose rivaroxaban, and warfarin in individuals aged 85 and older with atrial fibrillation (AF). DESIGN: Retrospective cohort study. SETTING: Taiwan National Health Insurance claims database, 2011∼2015. PARTICIPANTS: Individuals with AF aged 85 and older (mean 88.6) with incident use of oral anticoagulants between June 1, 2012 and May 31, 2015 (N=4,722; dabigatran 110 mg, n=1,489; rivaroxaban 15 mg/10 mg, n=1,736; warfarin, n=1,497). MEASUREMENTS: Clinical outcomes included all-cause death, cardiovascular death, ischemic stroke, acute myocardial infarction, arterial embolism or thrombosis, intracranial hemorrhage, and gastrointestinal hemorrhage needing transfusion. Propensity score-matched analysis was performed, and the marginal proportional hazards model was used to estimate the relative risk of various clinical outcomes in a matched dabigatran-warfarin cohort (n=1,180 in each group) and a rivaroxaban-warfarin cohort (n=1,207 in each group) RESULTS: Mean follow-up was 6.6 months for the overall population. Dabigatran group participants had lower risks of all-cause death (hazard ratio (HR)=0.59, 95% confidence interval (CI)=0.45-0.77) and cardiovascular death (HR=0.45, 95% CI=0.30-0.68) than warfarin group participants. Rivaroxaban users also had lower risks of all-cause death (HR=0.61, 95% CI=0.47-0.79) and cardiovascular death (HR=0.52, 95% CI=0.35-0.75) than warfarin users. Dabigatran users also had a lower risk of intracranial hemorrhage than warfarin users (HR=0.31, 95% CI=0.10-0.97). CONCLUSION: Individuals with AF aged 85 and older who used reduced-dose dabigatran or reduced-dose rivaroxaban had statistically significantly lower all-cause mortality and cardiovascular mortality than those who used warfarin. Reduced-dose dabigatran was also associated with lower risk of intracranial hemorrhage than warfarin.
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Lai et al. (2018) conducted a cohort in atrial fibrillation (n=4,722). Reduced-dose dabigatran or reduced-dose rivaroxaban vs. warfarin was evaluated on all-cause death (HR 0.59, 95% CI 0.45-0.77). Reduced-dose dabigatran and rivaroxaban were associated with lower risks of all-cause death (HR 0.59 and 0.61, respectively) compared to warfarin in adults aged ≥85 with atrial fibrillation.
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