What does this research mean for the field?

In patients with atrial fibrillation and a history of falls, non-vitamin K antagonist oral anticoagulants (NOACs), particularly apixaban, provide a better benefit-risk profile than vitamin K antagonists by lowering the risk of stroke and mortality without increasing bleeding risks. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

May 18, 2023Open Access

Clinical outcomes in patients with atrial fibrillation and a history of falls using non-vitamin K antagonist oral anticoagulants: A nationwide cohort study

Structured PICO

Do NOACs improve clinical outcomes compared to VKAs in patients with atrial fibrillation and a history of falls?

Population

254,478 patients with atrial fibrillation initiating anticoagulation between 2013 and 2019, of which 18,947 (7.4%) had a history of falls within 1 year prior to initiation, from a Belgian nationwide cohort.

Intervention

Non-vitamin K antagonist oral anticoagulants (NOACs) including apixaban, dabigatran, rivaroxaban, and edoxaban

Comparator

Vitamin K antagonists (VKAs)

Outcome

AF-related outcomes including stroke or systemic embolism, ischemic stroke, all-cause mortality, major bleeding, intracranial bleeding, gastrointestinal bleeding, and new fallshard clinical

NOACs demonstrate a superior benefit-risk profile compared to VKAs in atrial fibrillation patients with a history of falls, significantly reducing stroke and mortality risks.

Abstract

Background: Data on non-vitamin K antagonist oral anticoagulant (NOAC) use in patients with atrial fibrillation (AF) and a history of falls are limited. Therefore, we investigated the impact of a history of falls on AF-related outcomes, and the benefit-risk profiles of NOACs in patients with a history of falls. Methods: Using Belgian nationwide data, AF patients initiating anticoagulation between 2013 and 2019 were included. Previous falls that occurred ≤ 1 year before anticoagulant initiation were identified. Results: Among 254,478 AF patients, 18,947 (7.4%) subjects had a history of falls, which was associated with higher risks of all-cause mortality (adjusted hazard ratio (aHR) 1.11, 95%CI (1.06-1.15)), major bleeding (aHR 1.07, 95%CI (1.01-1.14)), intracranial bleeding (aHR 1.30, 95%CI (1.16-1.47)) and new falls (aHR 1.63, 95%CI (1.55-1.71)), but not with thromboembolism. Among subjects with a history of falls, NOACs were associated with lower risks of stroke or systemic embolism (aHR 0.70, 95%CI (0.57-0.87)), ischemic stroke (aHR 0.59, 95%CI (0.45-0.77)) and all-cause mortality (aHR 0.83, 95%CI (0.75-0.92)) compared to vitamin K antagonists (VKAs), while major, intracranial, and gastrointestinal bleeding risks were not significantly different. Major bleeding risks were significantly lower with apixaban (aHR 0.77, 95%CI (0.63-0.94)), but similar with other NOACs compared to VKAs. Apixaban was associated with lower major bleeding risks compared to dabigatran (aHR 0.78, 95%CI (0.62-0.98)), rivaroxaban (aHR 0.78, 95%CI (0.68-0.91)) and edoxaban (aHR 0.74, 95%CI (0.59-0.92)), but mortality risks were higher compared to dabigatran and edoxaban. Conclusions: A history of falls was an independent predictor of bleeding and death. NOACs had better benefit-risk profiles than VKAs in patients with a history of falls, especially apixaban.

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