The safety and persistence of non-vitamin-K-antagonist oral anticoagulants in atrial fibrillation patients treated in a well structured atrial fibrillation clinic

Abstract

Aims To examine the long-term persistence and safety of the non-vitamin-K-antagonist oral anticoagulants (NOACs) dabigatran (D), rivaroxaban (R) and apixaban (A) in patients with non-valvular atrial fibrillation (AF) treated in the framework of a well structured, nurse-based AF unit for initiation and follow-up of NOAC.

Methods Retrospective clinical data were collected for 766 consequent patients from a single cardiology outpatient clinic incorporating the AF unit.

Results The follow-up time, median (q1-q3), was 367 days (183–493) for D patients (n = 233), 432 days (255–546) for R patients (n = 282) and 348 days (267–419) for A patients (n = 251). No significant differences were found between the three groups with regard to age, sex, renal function, or CHA₂DS₂-VASc score. For all bleeding events the incidence rates per 100 patient-years of follow-up (95% confidence interval [CI], p-value) were reported more often for treatment with R (17.2, 12.7–22.8) than for D (7.0, 4.0–11.3, p = 0.001) and A (8.7, 5.2–13.6, p = 0.013). The differences remained significant after adjustment for clinically relevant variables. Discontinuation rates (n = 167) were lower for A (11.5, 7.5–16.8) than for D (30, 23.4–37.9, p < 0.001) and R (23.9, 18.6–30.1, p = 0.001), and were mainly attributed to drug-specific side effects and bleedings. The majority of discontinued patients (n = 142, 85%) proceeded with other types of oral anticoagulants.

Limitation The main limitation of the study is the small patient population with a short follow-up time.

Conclusion In a retrospective study at a single AF clinic, NOACs showed significantly different bleeding rates and varied discontinuation rates when compared to each other, related mainly to agent-specific side effects and bleedings. The majority of patients that discontinued proceeded with other types of oral anticoagulant.

Keywords:

• Apixaban
• atrial fibrillation
• dabigatran
• persistence
• rivaroxaban
• safety

Acknowledgments

We would like to thank Helena Johansson RN and Birgit Yeap RN for their high quality care of patients with atrial fibrillation at Stockholm Heart Center.

Previous presentation

Part of this paper was presented at the annual congress of the European Society of Cardiology in London, UK, 29 August–2 September 2015.

Notice of correction

Please note that Table 2 has been corrected since the article was first published online (10 February 2016).