Abstract
Objective
To determine risks of embolic events, bleeding, and mortality with direct oral anticoagulants
(DOACs) vs warfarin in people with atrial fibrillation (AF) and dementia.
Design
New-user retrospective cohort study using The Health Improvement Network database.
Setting and Participants
A population-based sample comprising people with AF and dementia prescribed DOACs
or warfarin from August 2011 to September 2017.
Methods
Risk of ischemic stroke (IS), ischemic stroke/transient ischemic attack/systemic embolism
(IS/TIA/SE), all-cause mortality, intracranial bleeding (ICB), gastrointestinal bleeding
(GIB), and other bleeding were compared for DOACs vs warfarin using propensity score–adjusted
Poisson regression. Incidence rate ratios (IRRs) and absolute risk differences (ARDs)
were calculated.
Results
Overall, 2399 people with AF and dementia initiated DOACs (42%) or warfarin (58%).
Before propensity score adjustment, patients who initiated DOACs were older and had
more comorbidities. After adjustment, DOAC initiators demonstrated similar risks of
IS, TIA, or SE; IS alone; and other bleeding but reduced ICB risk (IRR 0.27, 95% CI
0.08, 0.86; ARD −5.2, 95% CI –6.5, −1.0, per 1000 person-years) compared with warfarin.
Increased risk of GIB (IRR 2.11, 95% CI 1.30, 3.42; ARD 14.8, 95% CI 4.0, 32.4, per
1000 person-years) and all-cause mortality (IRR 2.06, 95% CI 1.60, 2.65; ARD 53.0,
95% CI 30.2, 82.8, per 1000 person-years) were observed in DOAC initiators compared
with warfarin.
Conclusions and Implications
Among people with AF and dementia, initiating treatment with DOACs compared with warfarin
was associated with similar risks of IS, TIA, or SE and IS alone. DOAC-treated patients
demonstrated reduced ICB risk but increased GIB and all-cause mortality risks. We
cannot exclude the possible impact of residual confounding from channeling of DOACs
toward older and sicker people, particularly for the outcome of all-cause mortality.
Further safety data are urgently needed to confirm findings.
Keywords
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Article info
Publication history
Published online: January 13, 2020
Footnotes
Conflicts of Interest: IW has received research grants from Hong Kong Research Grant Council, Pfizer, BMS, and Bayer in the research of anticoagulant use in patients with atrial fibrillation. KKL has received grant support relating to use of anticoagulants from Pfizer and Boehringer Ingelheim and served on the Advisory Board Committee of Boehringer Ingelheim regarding use of dabigatran. KM has received personal fee from IQVIA Ltd not related to this study. Other authors report no conflicts of interest in this work.
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© 2019 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
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