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. 2024 May 24;8(4):102449.
doi: 10.1016/j.rpth.2024.102449. eCollection 2024 May.

Outcomes of direct oral anticoagulants with aspirin vs warfarin with aspirin: a registry-based cohort study

Jordan K Schaefer  1 , Josh Errickson  2 , Xiaowen Kong  3 , Mona A Ali  4 , Deborah DeCamillo  3 , Subhash Edupuganti  5 , Brian Haymart  3 , Scott Kaatz  6 , Eva Kline-Rogers  3 , Jay H Kozlowski  7 , Gregory D Krol  8 , Suman L Sood  1 , James B Froehlich  3 , Geoffrey D Barnes  3
Affiliations

Outcomes of direct oral anticoagulants with aspirin vs warfarin with aspirin: a registry-based cohort study

Jordan K Schaefer et al. Res Pract Thromb Haemost. .

Abstract

Background: For patients anticoagulated with direct oral anticoagulants (DOACs) or warfarin and on aspirin (ASA) for nonvalvular atrial fibrillation and/or venous thromboembolism, it is unclear if bleeding outcomes differ.

Objectives: To assess bleeding rates for ASA with DOACs vs warfarin and one another.

Methods: Registry-based cohort study of patients followed by a 6-center quality improvement collaborative in Michigan using data from 2009 to 2022. The study included adults on ASA with warfarin or DOACs for atrial fibrillation and/or venous thromboembolism without a recent myocardial infarction or heart valve replacement.

Results: After propensity matching by anticoagulant class, we compared 2 groups of 1467 patients followed for a median of 18.0 months. Any bleeding and nonmajor bleeding was increased with DOACs + ASA compared with warfarin + ASA (32.2 vs 27.8 and 27.1 vs 22.9 events/100 patient-years; relative risks [RRs], 1.1 and 1.2; 95% CIs, 1.1-1.2 and 1.1-1.3, respectively). After matching by drug, patients on apixaban + ASA vs warfarin + ASA had more bleeding (31.2 vs 27.8 events/100 patient-years; RR, 1.1; 95% CI, 1.0-1.2) and nonmajor bleeding but less major bleeding (3.8 vs 4.7 events/100 patient-years; RR, 0.8; 95% CI, 0.6-1.0) and emergency room visits for bleeding. Patients on rivaroxaban + ASA vs warfarin + ASA had more bleeding (39.3 vs 26.3 events/100 patient-years, RR, 1.5; 95% CI, 1.3-1.6), nonmajor bleeding, and thrombosis. Patients on apixaban + ASA vs rivaroxaban + ASA had significantly less bleeding (22.5 vs 39.3/100 patient-years; RR, 0.6; 95% CI, 0.5-0.7), nonmajor bleeding, major bleeding (2.1 vs 5.5 events/100 patient-years; RR, 0.4; 95% CI, 0.2-0.6), emergency room visits for bleeding, and thrombotic events.

Conclusion: Patients on DOAC + ASA without a recent myocardial infarction or heart valve replacement had more nonmajor bleeding but otherwise similar outcomes compared with warfarin + ASA. Patients treated with rivaroxaban + ASA experienced more adverse clinical events compared with warfarin + ASA or apixaban + ASA.

Keywords: aspirin; factor Xa inhibitors; hemorrhage; outcome assessment; warfarin.

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Figures

Figure 1
Figure 1
Bar graph comparing outcomes of direct oral anticoagulants (DOACs) + acetylsalicylic acid or aspirin (ASA) with warfarin + ASA. Events per 100 patient-years. ASA, acetylsalicylic acid or aspirin.
Figure 2
Figure 2
Bar graph comparing outcomes of apixaban + acetylsalicylic acid or aspirin (ASA) with warfarin + ASA. Events per 100 patient-years.
Figure 3
Figure 3
Bar graph comparing outcomes of rivaroxaban + acetylsalicylic acid or aspirin (ASA) with warfarin + ASA. Events per 100 patient-years.
Figure 4
Figure 4
Bar graph comparing outcomes of apixaban + acetylsalicylic acid or aspirin (ASA) with rivaroxaban + ASA. Events per 100 patient-years.
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