Importance:Dabigatran and rivaroxaban are non-vitamin K oral anticoagulants approved for stroke prevention in patients with nonvalvular atrial fibrillation (AF). There are no randomized head-to-head comparisons of these drugs for stroke, bleeding, or mortality outcomes. Objective:To compare risks of thromboembolic stroke, intracranial hemorrhage (ICH), major extracranial bleeding including major gastrointestinal bleeding, and mortality in patients with nonvalvular AF who initiated dabigatran or rivaroxaban treatment for stroke prevention. Design, Setting, and Participants:Retrospective new-user cohort study of 118 891 patients with nonvalvular AF who were 65 years or older, enrolled in fee-for-service Medicare, and who initiated treatment with dabigatran or rivaroxaban from November 4, 2011, through June 30, 2014. Differences in baseline characteristics were adjusted using stabilized inverse probability of treatment weights based on propensity scores. The data analysis was performed from May 7, 2015, through June 30, 2016. Exposures:Dabigatran, 150 mg, twice daily; rivaroxaban, 20 mg, once daily. Main Outcomes and Measures:Adjusted hazard ratios (HRs) for the primary outcomes of thromboembolic stroke, ICH, major extracranial bleeding including major gastrointestinal bleeding, and mortality, with dabigatran as reference. Adjusted incidence rate differences (AIRDs) were also estimated. Results:A total of 52 240 dabigatran-treated and 66 651 rivaroxaban-treated patients (47% female) contributed 15 524 and 20 199 person-years of on-treatment follow-up, respectively, during which 2537 primary outcome events occurred. Rivaroxaban use was associated with a statistically nonsignificant reduction in thromboembolic stroke (HR, 0.81; 95% CI, 0.65-1.01; P = .07; AIRD = 1.8 fewer cases/1000 person-years), statistically significant increases in ICH (HR, 1.65; 95% CI, 1.20-2.26; P = .002; AIRD = 2.3 excess cases/1000 person-years) and major extracranial bleeding (HR, 1.48; 95% CI, 1.32-1.67; P < .001; AIRD = 13.0 excess cases/1000 person-years), including major gastrointestinal bleeding (HR, 1.40; 95% CI, 1.23-1.59; P < .001; AIRD = 9.4 excess cases/1000 person-years), and with a statistically nonsignificant increase in mortality (HR, 1.15; 95% CI, 1.00-1.32; P = .051; AIRD = 3.1 excess cases/1000 person-years). In patients 75 years or older or with CHADS2 score greater than 2, rivaroxaban use was associated with significantly increased mortality compared with dabigatran use. The excess rate of ICH with rivaroxaban use exceeded its reduced rate of thromboembolic stroke. Conclusions and Relevance:Treatment with rivaroxaban 20 mg once daily was associated with statistically significant increases in ICH and major extracranial bleeding, including major gastrointestinal bleeding, compared with dabigatran 150 mg twice daily.

译文

重要性:达比加群和利伐沙班是经批准用于非瓣膜性房颤(AF)患者的中风预防的非维生素K口服抗凝剂。这些药物在中风,出血或死亡率方面没有随机的头对头比较。
目的:比较开始使用达比加群或利伐沙班治疗的非瓣膜性房颤患者的血栓栓塞性中风,颅内出血(ICH),主要颅外出血(包括主要胃肠道出血)和死亡率的风险。
设计,背景和参与者:2011年11月对118891名65岁以上老年非瓣膜性房颤患者进行回顾性新使用者队列研究,参加了有偿服务的Medicare,并从2011年11月4日开始使用达比加群或利伐沙班治疗,直到2014年6月30日为止。基线特征的差异是根据倾向得分,使用稳定的治疗权重的逆概率进行调整的。数据分析的时间为2015年5月7日至2016年6月30日。
暴露:达比加群150毫克,每日两次;利伐沙班,20毫克,每天一次。
主要结果和措施:以达比加群为参考,对血栓栓塞性中风,ICH,主要颅外出血(包括主要胃肠道出血)和死亡率的主要结局调整后的危险比(HRs)。还估计了调整后的发病率差异(AIRD)。
结果:总共有52240例达比加群治疗和66651例利伐沙班治疗的患者(女性占47%)分别进行了15524和20199人年的治疗随访,其中发生了2537例主要预后事件。利伐沙班的使用与血栓栓塞性卒中的统计学上无统计学意义的降低(HR,0.81; 95%CI,0.65-1.01; P = .07; AIRD = 1.8病例/ 1000人-年)相比,ICH的统计学显着增加(HR, 1.65; 95%CI,1.20-2.26; P = .002; AIRD = 2.3超标病例/ 1000人年)和严重颅外出血(HR,1.48; 95%CI,1.32-1.67; P <.001; AIRD =每1 000人年增加13.0例),包括主要胃肠道出血(HR,1.40; 95%CI,1.23-1.59; P <.001; AIRD = 9.4超病情况/ 1000人年),且统计上无显着增加死亡率(HR,1.15; 95%CI,1.00-1.32; P = .051; AIRD = excess3.1超重病例/ 1000人年)。在75岁或以上或CHADS2评分大于2的患者中,与达比加群相比,利伐沙班的使用与死亡率显着增加有关。使用利伐沙班的ICH过量率超过了其降低的血栓栓塞性卒中率。
结论与相关性:与每日两次两次达比加群150 mg相比,每日一次利伐沙班20 mg治疗与ICH和主要颅外出血(包括主要胃肠道出血)的统计学显着增加相关。

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