Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients With Active Cancer

BACKGROUND Patients with cancer are more likely to develop nonvalvular atrial fibrillation (NVAF). Currently there are no definitive clinical trials or treatment guidelines for NVAF patients with concurrent cancer. OBJECTIVES This subgroup analysis of the ARISTOPHANES study compared the risk of stroke/systemic embolism (stroke/SE) and major bleeding (MB) among NVAF patients with active cancer who were prescribed non-vitamin K antagonist oral anticoagulants (NOACs) or warfarin. METHODS A retrospective observational study was conducted in NVAF patients with active cancer who newly initiated apixaban, dabigatran, rivaroxaban, or warfarin from January 1, 2013, through September 30, 2015, with the use of Medicare and 4 U.S. commercial claims databases. Cox models were used to estimate the risk of stroke/SE and MB in the pooled propensity score-matched cohorts. RESULTS A total of 40,271 patients were included, with main cancer types of prostate (29%), female breast (17%), genitourinary (14%), and lung (13%). Compared with warfarin, apixaban was associated with a tower risk of stroke/SE (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.45-0.78) and MB (HR: 0.58; 95% CI: 0.50-0.68); dabigatran and rivaroxaban had similar risks of stroke/SE (dabigatran: HR: 0.88 [95% CI: 0.54-1.41]; rivaroxaban: HR: 0.82 [95% CI: 0.62-1.08]) and MB (dabigatran: HR: 0.76 [95% CI: 0.57-1.01]; rivaroxaban: HR: 0.95 [95% 0: 0.85-1.06]). Risks of stroke/SE and MB varied among NOAC-NOAC comparisons, white consistent treatment effects were seen for all treatment comparisons across key cancer types. CONCLUSIONS Among this cohort of NVAF patients with active cancer, the risk of stroke/SE and MB varied among oral anticoagulants and were consistent across cancer types. (C) 2021 Published by Elsevier on behalf of the American College of Cardiology Foundation.

Automated summary

This study found that among patients with nonvalvular atrial fibrillation and concurrent cancer, apixaban was associated with lower risk of stroke/systemic embolism and major bleeding compared to warfarin, while dabigatran and rivaroxaban had similar risks. There were variations in risk among different NOACs, but consistent treatment effects were seen across different types of cancer.