Effectiveness and Safety of Dabigatran, Rivaroxaban, and Apixaban Versus Warfarin in Nonvalvular Atrial Fibrillation

Abstract

Background: The introduction of non-vitamin K antagonist oral anticoagulants has been a major advance for stroke prevention in atrial fibrillation; however, outcomes achieved in clinical trials may not translate to routine practice. We aimed to evaluate the effectiveness and safety of dabigatran, rivaroxaban, and apixaban by comparing each agent with warfarin.

Methods and results: Using a large US insurance database, we identified privately insured and Medicare Advantage patients with nonvalvular atrial fibrillation who were users of apixaban, dabigatran, rivaroxaban, or warfarin between October 1, 2010, and June 30, 2015. We created 3 matched cohorts using 1:1 propensity score matching: apixaban versus warfarin (n=15 390), dabigatran versus warfarin (n=28 614), and rivaroxaban versus warfarin (n=32 350). Using Cox proportional hazards regression, we found that for stroke or systemic embolism, apixaban was associated with lower risk (hazard ratio [HR] 0.67, 95% CI 0.46-0.98, P=0.04), but dabigatran and rivaroxaban were associated with a similar risk (dabigatran: HR 0.98, 95% CI 0.76-1.26, P=0.98; rivaroxaban: HR 0.93, 95% CI 0.72-1.19, P=0.56). For major bleeding, apixaban and dabigatran were associated with lower risk (apixaban: HR 0.45, 95% CI 0.34-0.59, P<0.001; dabigatran: HR 0.79, 95% CI 0.67-0.94, P<0.01), and rivaroxaban was associated with a similar risk (HR 1.04, 95% CI 0.90-1.20], P=0.60). All non-vitamin K antagonist oral anticoagulants were associated with a lower risk of intracranial bleeding.

Conclusions: In patients with nonvalvular atrial fibrillation, apixaban was associated with lower risks of both stroke and major bleeding, dabigatran was associated with similar risk of stroke but lower risk of major bleeding, and rivaroxaban was associated with similar risks of both stroke and major bleeding in comparison to warfarin.

Keywords: atrial fibrillation; bleeding; non–vitamin K antagonist oral anticoagulants; stroke; warfarin.

Figure 1

Cohort creation flowchart. AF indicates atrial fibrillation; ESRD, end‐stage renal disease; OAC, oral anticoagulants; VTE, venous thromboembolism.

Figure 2

Forest plot depicting the hazard ratio for each pairwise propensity‐matched medication comparison (dabigatran, rivaroxaban, and apixaban each vs warfarin) for stroke and systemic embolism (S/SE), ischemic stroke, and hemorrhagic stroke. NOAC, non–vitamin K oral anticoagulant.

Figure 3

Forest plot depicting the hazard ratio for each pairwise propensity‐matched medication comparison (dabigatran, rivaroxaban, and apixaban each vs warfarin) for major, intracranial, and gastrointestinal bleeding. NOAC, non–vitamin K oral anticoagulant.