Clinical Effectiveness of Direct Oral Anticoagulants vs Warfarin in Older Patients with Atrial Fibrillation and Ischemic Stroke: Findings from the Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study

Ying Xian, Haolin Xu, Emily C. O'Brien, Shreyansh Shah, Laine Thomas, Michael J. Pencina, Gregg C. Fonarow, Daiwai M. Olson, Lee H. Schwamm, Deepak L. Bhatt, Eric E. Smith, Deidre Hannah, Lesley Maisch, Barbara L. Lytle, Eric D. Peterson, Adrian F. Hernandez

Research output: Contribution to journalArticle

9 Scopus citations

Abstract

Importance: Current guidelines recommend direct oral anticoagulants (DOACs) over warfarin for stroke prevention in patients with atrial fibrillation (AF) who are at high risk. Despite demonstrated efficacy in clinical trials, real-world data of DOACs vs warfarin for secondary prevention in patients with ischemic stroke are largely based on administrative claims or have not focused on patient-centered outcomes. Objective: To examine the clinical effectiveness of DOACs (dabigatran, rivaroxaban, or apixaban) vs warfarin after ischemic stroke in patients with AF. Design, Setting, and Participants: This cohort study included patients who were 65 years or older, had AF, were anticoagulation naive, and were discharged from 1041 Get With The Guidelines-Stroke-associated hospitals for acute ischemic stroke between October 2011 and December 2014. Data were linked to Medicare claims for long-term outcomes (up to December 2015). Analyses were completed in July 2018. Exposures: DOACs vs warfarin prescription at discharge. Main Outcomes and Measures: The primary outcomes were home time, a patient-centered measure defined as the total number of days free from death and institutional care after discharge, and major adverse cardiovascular events. A propensity score-overlap weighting method was used to account for differences in observed characteristics between groups. Results: Of 11662 survivors of acute ischemic stroke (median [interquartile range] age, 80 [74-86] years), 4041 (34.7%) were discharged with DOACs and 7621 with warfarin. Except for National Institutes of Health Stroke Scale scores (median [interquartile range], 4 [1-9] vs 5 [2-11]), baseline characteristics were similar between groups. Patients discharged with DOACs (vs warfarin) had more days at home (mean [SD], 287.2 [114.7] vs 263.0 [127.3] days; adjusted difference, 15.6 [99% CI, 9.0-22.1] days) during the first year postdischarge and were less likely to experience major adverse cardiovascular events (adjusted hazard ratio [aHR], 0.89 [99% CI, 0.83-0.96]). Also, in patients receiving DOACs, there were fewer deaths (aHR, 0.88 [95% CI, 0.82-0.95]; P <.001), all-cause readmissions (aHR, 0.93 [95% CI, 0.88-0.97]; P =.003), cardiovascular readmissions (aHR, 0.92 [95% CI, 0.86-0.99]; P =.02), hemorrhagic strokes (aHR, 0.69 [95% CI, 0.50-0.95]; P =.02), and hospitalizations with bleeding (aHR, 0.89 [95% CI, 0.81-0.97]; P =.009) but a higher risk of gastrointestinal bleeding (aHR, 1.14 [95% CI, 1.01-1.30]; P =.03). Conclusions and Relevance: In patients with acute ischemic stroke and AF, DOAC use at discharge was associated with better long-term outcomes relative to warfarin.

Original languageEnglish (US)
Pages (from-to)1192-1202
Number of pages11
JournalJAMA neurology
Volume76
Issue number10
DOIs
StatePublished - Oct 2019

ASJC Scopus subject areas

  • Clinical Neurology

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    Xian, Y., Xu, H., O'Brien, E. C., Shah, S., Thomas, L., Pencina, M. J., Fonarow, G. C., Olson, D. M., Schwamm, L. H., Bhatt, D. L., Smith, E. E., Hannah, D., Maisch, L., Lytle, B. L., Peterson, E. D., & Hernandez, A. F. (2019). Clinical Effectiveness of Direct Oral Anticoagulants vs Warfarin in Older Patients with Atrial Fibrillation and Ischemic Stroke: Findings from the Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study. JAMA neurology, 76(10), 1192-1202. https://doi.org/10.1001/jamaneurol.2019.2099