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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.

dc.contributor.author Xian, Ying
dc.contributor.author O'Brien, Emily
dc.contributor.author Pencina, Michael
dc.contributor.author Xu, Haolin
dc.contributor.author Shah, Shreyansh
dc.contributor.author Thomas, Laine
dc.contributor.author Fonarow, Gregg C
dc.contributor.author Olson, DaiWai M
dc.contributor.author Schwamm, Lee H
dc.contributor.author Bhatt, Deepak L
dc.contributor.author Smith, Eric E
dc.contributor.author Hannah, Deidre
dc.contributor.author Maisch, Lesley
dc.contributor.author Lytle, Barbara L
dc.contributor.author Peterson, Eric D
dc.contributor.author Hernandez, Adrian F
dc.date.accessioned 2019-08-01T14:40:31Z
dc.date.available 2019-08-01T14:40:31Z
dc.date.issued 2019-07-22
dc.identifier 2737806
dc.identifier.issn 2168-6149
dc.identifier.issn 2168-6157
dc.identifier.uri https://hdl.handle.net/10161/19138
dc.description.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 11 662 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.
dc.language eng
dc.publisher American Medical Association (AMA)
dc.relation.ispartof JAMA neurology
dc.relation.isversionof 10.1001/jamaneurol.2019.2099
dc.title 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.
dc.type Journal article
duke.contributor.id Xian, Ying|0542290
duke.contributor.id O'Brien, Emily|0291502
duke.contributor.id Pencina, Michael|0610685
dc.date.updated 2019-08-01T14:40:31Z
pubs.organisational-group School of Medicine
pubs.organisational-group Duke
pubs.organisational-group Duke Clinical Research Institute
pubs.organisational-group Institutes and Centers
pubs.organisational-group Neurology, Neurocritical Care
pubs.organisational-group Neurology
pubs.organisational-group Clinical Science Departments
pubs.organisational-group Medicine, Clinical Pharmacology
pubs.organisational-group Medicine
pubs.organisational-group Population Health Sciences
pubs.organisational-group Basic Science Departments
pubs.organisational-group Biostatistics & Bioinformatics
pubs.publication-status Published
duke.contributor.orcid Xian, Ying|0000-0002-1237-1162


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