• Ghadeer K Dawwas, Eric Dietrich, Adam Cuker, Geoffrey D Barnes, Charles E Leonard, and James D Lewis.
• Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L.).
• Ann. Intern. Med. 2021 Jul 1; 174 (7): 910-919.

BackgroundDirect oral anticoagulants (DOACs) are increasingly used in place of warfarin, but evidence about their effectiveness and safety in patients with valvular atrial fibrillation (AF) remains limited.ObjectiveTo assess the effectiveness and safety of DOACs compared with warfarin in patients with valvular AF.DesignNew-user retrospective propensity score-matched cohort study.SettingU.S.-based commercial health care database from 1 January 2010 to 30 June 2019.ParticipantsAdults with valvular AF who were newly prescribed DOACs or warfarin.MeasurementsThe primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial or gastrointestinal bleeding.ResultsAmong a total of 56 336 patients with valvular AF matched on propensity score, use of DOACs (vs. warfarin) was associated with lower risk for ischemic stroke or systemic embolism (hazard ratio [HR], 0.64 [95% CI, 0.59 to 0.70]) and major bleeding events (HR, 0.67 [CI, 0.63 to 0.72]). The results for the effectiveness and safety outcomes remained consistent for apixaban (HRs, 0.54 [CI, 0.47 to 0.61] and 0.52 [CI, 0.47 to 0.57], respectively) and rivaroxaban (HRs, 0.74 [CI, 0.64 to 0.86] and 0.87 [CI, 0.79 to 0.96], respectively); with dabigatran, results were consistent for the major bleeding outcome (HR, 0.81 [CI, 0.68 to 0.97]) but not for effectiveness (HR, 1.03 [CI, 0.81 to 1.31]).LimitationRelatively short follow-up; inability to ascertain disease severity.ConclusionIn this comparative effectiveness study using practice-based claims data, patients with valvular AF who were new users of DOACs had lower risks for ischemic stroke or systemic embolism and major bleeding than new users of warfarin. These data may be used to guide risk-benefit discussions regarding anticoagulant choices for patients with valvular AF.Primary Funding SourceNone.

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