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Comparison of the Effectiveness and Safety of Apixaban, Dabigatran, Rivaroxaban, and Warfarin in Newly Diagnosed Atrial Fibrillation
No studies have performed direct pairwise comparisons of the effectiveness and safety of warfarin and the new oral anticoagulants (NOACs) apixaban, dabigatran, and rivaroxaban. Using 2013 to 2014 claims from a 5% random sample of Medicare beneficiaries, we identified patients newly diagnosed with at...
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| Published in: | The American journal of cardiology 2017-11, Vol.120 (10), p.1813-1819 |
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| creator | Hernandez, Inmaculada Zhang, Yuting Saba, Samir |
| description | No studies have performed direct pairwise comparisons of the effectiveness and safety of warfarin and the new oral anticoagulants (NOACs) apixaban, dabigatran, and rivaroxaban. Using 2013 to 2014 claims from a 5% random sample of Medicare beneficiaries, we identified patients newly diagnosed with atrial fibrillation who initiated apixaban, dabigatran, rivaroxaban, warfarin, or no oral anticoagulation therapy in 2013 to 2014. Outcomes included the composite of ischemic stroke, systemic embolism (SE) and death, any bleeding event, gastrointestinal bleeding, intracranial bleeding, and treatment persistence. We constructed Cox proportional hazard models to compare outcomes between each pair of treatment groups. The composite risk of ischemic stroke, SE, and death was lower for NOACs than for warfarin: hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.76 to 0.98 for apixaban; 0.73, 95% CI 0.63 to 0.86 for dabigatran; and 0.82, 95% CI 0.75 to 0.89 for rivaroxaban, all compared with warfarin. There were no differences in effectiveness across NOACs. The risk of any bleeding was lower with apixaban than with warfarin, but higher with rivaroxaban than with warfarin. Apixaban (HR 0.69, 95% CI 0.60 to 0.79) and dabigatran (HR 0.79, 95% CI 0.69 to 0.92) were associated with lower bleeding risk than rivaroxaban. Treatment persistence was highest for apixaban (82%), and lowest for dabigatran and warfarin (64%) (p value |
| doi_str_mv | 10.1016/j.amjcard.2017.07.092 |
| format | article |
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Using 2013 to 2014 claims from a 5% random sample of Medicare beneficiaries, we identified patients newly diagnosed with atrial fibrillation who initiated apixaban, dabigatran, rivaroxaban, warfarin, or no oral anticoagulation therapy in 2013 to 2014. Outcomes included the composite of ischemic stroke, systemic embolism (SE) and death, any bleeding event, gastrointestinal bleeding, intracranial bleeding, and treatment persistence. We constructed Cox proportional hazard models to compare outcomes between each pair of treatment groups. The composite risk of ischemic stroke, SE, and death was lower for NOACs than for warfarin: hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.76 to 0.98 for apixaban; 0.73, 95% CI 0.63 to 0.86 for dabigatran; and 0.82, 95% CI 0.75 to 0.89 for rivaroxaban, all compared with warfarin. There were no differences in effectiveness across NOACs. The risk of any bleeding was lower with apixaban than with warfarin, but higher with rivaroxaban than with warfarin. Apixaban (HR 0.69, 95% CI 0.60 to 0.79) and dabigatran (HR 0.79, 95% CI 0.69 to 0.92) were associated with lower bleeding risk than rivaroxaban. Treatment persistence was highest for apixaban (82%), and lowest for dabigatran and warfarin (64%) (p value <0.001). Compared with warfarin, NOACs are more effective in preventing stroke but their risk of bleeding varies, with rivaroxaban having higher risk than warfarin. Altogether, apixaban had the most favorable effectiveness, safety, and persistence profile.</description><identifier>ISSN: 0002-9149</identifier><identifier>EISSN: 1879-1913</identifier><identifier>DOI: 10.1016/j.amjcard.2017.07.092</identifier><identifier>PMID: 28864318</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject><![CDATA[Administration, Oral ; Aged ; Anticoagulants ; Anticoagulants - administration & dosage ; Antithrombins - administration & dosage ; Atrial Fibrillation - complications ; Atrial Fibrillation - diagnosis ; Atrial Fibrillation - drug therapy ; Bleeding ; Cardiac arrhythmia ; Coagulation ; Confidence intervals ; Dabigatran - administration & dosage ; Dose-Response Relationship, Drug ; Embolism ; Embolism - epidemiology ; Embolism - prevention & control ; Factor Xa Inhibitors - administration & dosage ; Female ; Fibrillation ; Follow-Up Studies ; Government programs ; Health care ; Humans ; Incidence ; Ischemia ; Male ; Pennsylvania - epidemiology ; Pyrazoles - administration & dosage ; Pyridones - administration & dosage ; Retrospective Studies ; Risk ; Rivaroxaban - administration & dosage ; Safety ; Stroke ; Stroke - epidemiology ; Stroke - etiology ; Stroke - prevention & control ; Treatment Outcome ; Warfarin ; Warfarin - administration & dosage]]></subject><ispartof>The American journal of cardiology, 2017-11, Vol.120 (10), p.1813-1819</ispartof><rights>2017 Elsevier Inc.</rights><rights>Copyright © 2017 Elsevier Inc. 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Nov 15, 2017</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c459t-33501ae23d664c18850af6804b2f152c20bdc9508809c7ec2444313cf8beee373</citedby><cites>FETCH-LOGICAL-c459t-33501ae23d664c18850af6804b2f152c20bdc9508809c7ec2444313cf8beee373</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>315,786,790,27957,27958</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/28864318$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Hernandez, Inmaculada</creatorcontrib><creatorcontrib>Zhang, Yuting</creatorcontrib><creatorcontrib>Saba, Samir</creatorcontrib><title>Comparison of the Effectiveness and Safety of Apixaban, Dabigatran, Rivaroxaban, and Warfarin in Newly Diagnosed Atrial Fibrillation</title><title>The American journal of cardiology</title><addtitle>Am J Cardiol</addtitle><description>No studies have performed direct pairwise comparisons of the effectiveness and safety of warfarin and the new oral anticoagulants (NOACs) apixaban, dabigatran, and rivaroxaban. Using 2013 to 2014 claims from a 5% random sample of Medicare beneficiaries, we identified patients newly diagnosed with atrial fibrillation who initiated apixaban, dabigatran, rivaroxaban, warfarin, or no oral anticoagulation therapy in 2013 to 2014. Outcomes included the composite of ischemic stroke, systemic embolism (SE) and death, any bleeding event, gastrointestinal bleeding, intracranial bleeding, and treatment persistence. We constructed Cox proportional hazard models to compare outcomes between each pair of treatment groups. The composite risk of ischemic stroke, SE, and death was lower for NOACs than for warfarin: hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.76 to 0.98 for apixaban; 0.73, 95% CI 0.63 to 0.86 for dabigatran; and 0.82, 95% CI 0.75 to 0.89 for rivaroxaban, all compared with warfarin. There were no differences in effectiveness across NOACs. The risk of any bleeding was lower with apixaban than with warfarin, but higher with rivaroxaban than with warfarin. Apixaban (HR 0.69, 95% CI 0.60 to 0.79) and dabigatran (HR 0.79, 95% CI 0.69 to 0.92) were associated with lower bleeding risk than rivaroxaban. Treatment persistence was highest for apixaban (82%), and lowest for dabigatran and warfarin (64%) (p value <0.001). Compared with warfarin, NOACs are more effective in preventing stroke but their risk of bleeding varies, with rivaroxaban having higher risk than warfarin. Altogether, apixaban had the most favorable effectiveness, safety, and persistence profile.</description><subject>Administration, Oral</subject><subject>Aged</subject><subject>Anticoagulants</subject><subject>Anticoagulants - administration & dosage</subject><subject>Antithrombins - administration & dosage</subject><subject>Atrial Fibrillation - complications</subject><subject>Atrial Fibrillation - diagnosis</subject><subject>Atrial Fibrillation - drug therapy</subject><subject>Bleeding</subject><subject>Cardiac arrhythmia</subject><subject>Coagulation</subject><subject>Confidence intervals</subject><subject>Dabigatran - administration & dosage</subject><subject>Dose-Response Relationship, Drug</subject><subject>Embolism</subject><subject>Embolism - epidemiology</subject><subject>Embolism - prevention & control</subject><subject>Factor Xa Inhibitors - administration & dosage</subject><subject>Female</subject><subject>Fibrillation</subject><subject>Follow-Up Studies</subject><subject>Government programs</subject><subject>Health care</subject><subject>Humans</subject><subject>Incidence</subject><subject>Ischemia</subject><subject>Male</subject><subject>Pennsylvania - 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administration & dosage</topic><topic>Antithrombins - administration & dosage</topic><topic>Atrial Fibrillation - complications</topic><topic>Atrial Fibrillation - diagnosis</topic><topic>Atrial Fibrillation - drug therapy</topic><topic>Bleeding</topic><topic>Cardiac arrhythmia</topic><topic>Coagulation</topic><topic>Confidence intervals</topic><topic>Dabigatran - administration & dosage</topic><topic>Dose-Response Relationship, Drug</topic><topic>Embolism</topic><topic>Embolism - epidemiology</topic><topic>Embolism - prevention & control</topic><topic>Factor Xa Inhibitors - administration & dosage</topic><topic>Female</topic><topic>Fibrillation</topic><topic>Follow-Up Studies</topic><topic>Government programs</topic><topic>Health care</topic><topic>Humans</topic><topic>Incidence</topic><topic>Ischemia</topic><topic>Male</topic><topic>Pennsylvania - epidemiology</topic><topic>Pyrazoles - administration & dosage</topic><topic>Pyridones - administration & dosage</topic><topic>Retrospective Studies</topic><topic>Risk</topic><topic>Rivaroxaban - administration & dosage</topic><topic>Safety</topic><topic>Stroke</topic><topic>Stroke - epidemiology</topic><topic>Stroke - etiology</topic><topic>Stroke - prevention & control</topic><topic>Treatment Outcome</topic><topic>Warfarin</topic><topic>Warfarin - administration & dosage</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Hernandez, Inmaculada</creatorcontrib><creatorcontrib>Zhang, Yuting</creatorcontrib><creatorcontrib>Saba, Samir</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Nursing & Allied Health Database</collection><collection>Physical Education Index</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Technology Research Database</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni)</collection><collection>ProQuest Central</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>PML(ProQuest Medical Library)</collection><collection>Research Library</collection><collection>Biochemistry Abstracts 1</collection><collection>Research Library (Corporate)</collection><collection>Nursing & Allied Health Premium</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>ProQuest Central Basic</collection><jtitle>The American journal of cardiology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Hernandez, Inmaculada</au><au>Zhang, Yuting</au><au>Saba, Samir</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Comparison of the Effectiveness and Safety of Apixaban, Dabigatran, Rivaroxaban, and Warfarin in Newly Diagnosed Atrial Fibrillation</atitle><jtitle>The American journal of cardiology</jtitle><addtitle>Am J Cardiol</addtitle><date>2017-11-15</date><risdate>2017</risdate><volume>120</volume><issue>10</issue><spage>1813</spage><epage>1819</epage><pages>1813-1819</pages><issn>0002-9149</issn><eissn>1879-1913</eissn><abstract>No studies have performed direct pairwise comparisons of the effectiveness and safety of warfarin and the new oral anticoagulants (NOACs) apixaban, dabigatran, and rivaroxaban. Using 2013 to 2014 claims from a 5% random sample of Medicare beneficiaries, we identified patients newly diagnosed with atrial fibrillation who initiated apixaban, dabigatran, rivaroxaban, warfarin, or no oral anticoagulation therapy in 2013 to 2014. Outcomes included the composite of ischemic stroke, systemic embolism (SE) and death, any bleeding event, gastrointestinal bleeding, intracranial bleeding, and treatment persistence. We constructed Cox proportional hazard models to compare outcomes between each pair of treatment groups. The composite risk of ischemic stroke, SE, and death was lower for NOACs than for warfarin: hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.76 to 0.98 for apixaban; 0.73, 95% CI 0.63 to 0.86 for dabigatran; and 0.82, 95% CI 0.75 to 0.89 for rivaroxaban, all compared with warfarin. There were no differences in effectiveness across NOACs. The risk of any bleeding was lower with apixaban than with warfarin, but higher with rivaroxaban than with warfarin. Apixaban (HR 0.69, 95% CI 0.60 to 0.79) and dabigatran (HR 0.79, 95% CI 0.69 to 0.92) were associated with lower bleeding risk than rivaroxaban. Treatment persistence was highest for apixaban (82%), and lowest for dabigatran and warfarin (64%) (p value <0.001). Compared with warfarin, NOACs are more effective in preventing stroke but their risk of bleeding varies, with rivaroxaban having higher risk than warfarin. Altogether, apixaban had the most favorable effectiveness, safety, and persistence profile.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>28864318</pmid><doi>10.1016/j.amjcard.2017.07.092</doi><tpages>7</tpages></addata></record> |
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| subjects | Administration, Oral Aged Anticoagulants Anticoagulants - administration & dosage Antithrombins - administration & dosage Atrial Fibrillation - complications Atrial Fibrillation - diagnosis Atrial Fibrillation - drug therapy Bleeding Cardiac arrhythmia Coagulation Confidence intervals Dabigatran - administration & dosage Dose-Response Relationship, Drug Embolism Embolism - epidemiology Embolism - prevention & control Factor Xa Inhibitors - administration & dosage Female Fibrillation Follow-Up Studies Government programs Health care Humans Incidence Ischemia Male Pennsylvania - epidemiology Pyrazoles - administration & dosage Pyridones - administration & dosage Retrospective Studies Risk Rivaroxaban - administration & dosage Safety Stroke Stroke - epidemiology Stroke - etiology Stroke - prevention & control Treatment Outcome Warfarin Warfarin - administration & dosage |
| title | Comparison of the Effectiveness and Safety of Apixaban, Dabigatran, Rivaroxaban, and Warfarin in Newly Diagnosed Atrial Fibrillation |
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