Comparative safety and effectiveness of direct oral anticoagulants in patients with atrial fibrillation in clinical practice in Scotland

Mueller, T., Alvarez-Madrazo, S., Robertson, C., Wu, O. and Bennie, M. (2018) Comparative safety and effectiveness of direct oral anticoagulants in patients with atrial fibrillation in clinical practice in Scotland. British Journal of Clinical Pharmacology, 85(2), pp. 422-431. (doi: 10.1111/bcp.13814) (PMID:30423191) (PMCID:PMC6339970)

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Abstract

To compare the clinical effectiveness and safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) in routine clinical practice. Retrospective cohort study using linked administrative data. The study population (n=14,577) included patients with a diagnosis of AF (confirmed in hospital) who initiated DOAC treatment in Scotland between August 2011 and December 2015. Multivariate Cox proportional hazard models were used to estimate hazard ratios of thromboembolic events, mortality, and bleeding events. No differences between the DOACs were observed in the risks of stroke, systemic embolism, or cardiovascular death. In contrast, the risk of myocardial infarction was higher among apixaban patients in comparison to rivaroxaban (1.67 [1.02 - 2.71]), and all-cause mortality was higher among rivaroxaban patients in contrast to both apixaban (1.22 [1.01 - 1.47]) and dabigatran (1.55 [1.16 - 2.05]); rivaroxaban patients also had a higher risk of pulmonary embolism than apixaban patients (5.27 [1.79 - 15.53]). The risk of other major bleeds was higher among rivaroxaban patients compared to apixaban (1.50 [1.10 - 2.03]) and dabigatran (1.58 [1.01 - 2.48]); the risks of gastro-intestinal bleeds and overall bleeding were higher among rivaroxaban patients than among apixaban patients (1.48 [1.01 - 2.16] and 1.52[1.21 - 1.92], respectively). All DOACs were similarly effective in preventing strokes and systemic embolisms, while patients being treated with rivaroxaban exhibited the highest bleeding risks. Observed differences in the risks of all-cause mortality, myocardial infarction, and pulmonary embolism warrant further research. [Abstract copyright: This article is protected by copyright. All rights reserved.]

Item Type:Articles
Additional Information:We acknowledge the funding support from The Farr Institute @ Scotland. The Farr Institute @ Scotland is supported by a 10‐funder consortium: Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Engineering and Physical Science Research Council, the Medical Research Council, the National Institute of Health Research, the National Institute for Social Care and Health Research (Welsh Assembly Government), the Chief Scientist Office (Scottish Government Health Directorates), the Wellcome Trust (MRC Grant No: MR/K007017/1).
Keywords:DOAC, anticoagulants, atrial fibrillation, clinical effectiveness, safety.
Status:Published
Refereed:Yes
Glasgow Author(s) Enlighten ID:Wu, Professor Olivia
Authors: Mueller, T., Alvarez-Madrazo, S., Robertson, C., Wu, O., and Bennie, M.
College/School:College of Medical Veterinary and Life Sciences > Institute of Health and Wellbeing > Health Economics and Health Technology Assessment
Journal Name:British Journal of Clinical Pharmacology
Publisher:Wiley
ISSN:0306-5251
ISSN (Online):1365-2125
Copyright Holders:Copyright © 2018 The Authors
First Published:First published in British Journal of Clinical Psychology 85:422-431
Publisher Policy:Reproduced under a Creative Commons License

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Project CodeAward NoProject NamePrincipal InvestigatorFunder's NameFunder RefLead Dept
190658The Scottish eHealth Informatics Research Centre (E-HIRCs).Jill PellMedical Research Council (MRC)MR/K007017/1HW - Public Health