Effectiveness and Safety of Dabigatran, Rivaroxaban, and Apixaban Versus Warfarin in Nonvalvular Atrial Fibrillation

<jats:sec xml:lang="en"> <jats:title>Background</jats:title> <jats:p xml:lang="en">The introduction of non–vitamin K antagonist oral anticoagulants has been a major advance for stroke prevention in atrial fibrillation; however, outcomes achieved in clinical trials may not translate to routine practice. We aimed to evaluate the effectiveness and safety of dabigatran, rivaroxaban, and apixaban by comparing each agent with warfarin.</jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Methods and Results</jats:title> <jats:p xml:lang="en"> Using a large US insurance database, we identified privately insured and Medicare Advantage patients with nonvalvular atrial fibrillation who were users of apixaban, dabigatran, rivaroxaban, or warfarin between October 1, 2010, and June 30, 2015. We created 3 matched cohorts using 1:1 propensity score matching: apixaban versus warfarin (n=15 390), dabigatran versus warfarin (n=28 614), and rivaroxaban versus warfarin (n=32 350). Using Cox proportional hazards regression, we found that for stroke or systemic embolism, apixaban was associated with lower risk (hazard ratio [ <jats:styled-content style="fixed-case">HR</jats:styled-content> ] 0.67, 95% CI 0.46–0.98, <jats:italic>P</jats:italic> =0.04), but dabigatran and rivaroxaban were associated with a similar risk (dabigatran: <jats:styled-content style="fixed-case">HR</jats:styled-content> 0.98, 95% CI 0.76–1.26, <jats:italic>P</jats:italic> =0.98; rivaroxaban: <jats:styled-content style="fixed-case">HR</jats:styled-content> 0.93, 95% CI 0.72–1.19, <jats:italic>P</jats:italic> =0.56). For major bleeding, apixaban and dabigatran were associated with lower risk (apixaban: <jats:styled-content style="fixed-case">HR</jats:styled-content> 0.45, 95% CI 0.34–0.59, <jats:italic>P</jats:italic> <0.001; dabigatran: <jats:styled-content style="fixed-case">HR</jats:styled-content> 0.79, 95% CI 0.67–0.94, <jats:italic>P</jats:italic> <0.01), and rivaroxaban was associated with a similar risk ( <jats:styled-content style="fixed-case">HR</jats:styled-content> 1.04, 95% CI 0.90–1.20], <jats:italic>P</jats:italic> =0.60). All non–vitamin K antagonist oral anticoagulants were associated with a lower risk of intracranial bleeding. </jats:p> </jats:sec> <jats:sec xml:lang="en"> <jats:title>Conclusions</jats:title> <jats:p xml:lang="en">In patients with nonvalvular atrial fibrillation, apixaban was associated with lower risks of both stroke and major bleeding, dabigatran was associated with similar risk of stroke but lower risk of major bleeding, and rivaroxaban was associated with similar risks of both stroke and major bleeding in comparison to warfarin.</jats:p> </jats:sec>