OBJECTIVES Nonagenarian patients are underrepresented in clinical trials that have evaluated oral anticoagulation in patients with atrial fibrillation (AF). The aim of this study was to assess the pronostic impact of oral anticoagulation in patients with AF age ≥90 years. DESIGN Retrospective multicenter study of nonagenarian patients with AF. SETTING AND PARTICIPANTS A total of 1750 nonagenarian inpatients and outpatients with nonvalvular AF between January 2013 and December 2018 in 3 Spanish health areas were studied. METHODS Patients were divided into 3 groups based on antithrombotic therapy: nonoral anticoagulants (30.5%), vitamin-K antagonists (VKAs; 28.6%), and direct oral anticoagulants (DOACs; 40.9%). During a mean follow-up of 23.6 ± 6.6 months, efficacy outcomes (death and embolic events) were evaluated using a Cox regression analysis and safety outcomes (bleeding requiring hospitalization) by competing-risk regression. Results were complemented with a propensity score matching analysis. RESULTS During follow-up, 988 patients died (56.5%), 180 had embolic events (10.3%), and 186 had major bleeding (10.6%). After multivariable adjustment, DOACs were associated with a lower risk of death and embolic events than nonanticoagulation [hazard ratio (HR) 0.75, 95% confidence interval (CI)] 0.61‒0.92), but VKAs were not (HR 0.87, 95% CI 0.72‒1.05). These results were confirmed after propensity score matching analysis. For bleeding, both DOACs and VKAs proved to be associated with a higher risk (HR for DOAC 1.43; 95% CI 0.97‒2.13; HR for VKA 1.94; 95% CI 1.31‒2.88), although findings for DOACs were not statistically significant (P = .074). For intracranial hemorrhage (ICH), only VKAs-not DOACs-presented a higher risk of ICH (HR 4.43; 95% CI 1.48‒13.31). CONCLUSIONS AND IMPLICATIONS In nonagenarian patients with AF, DOACs led to a reduction in mortality and embolic events in comparison with nonanticoagulation. This reduction was not observed with VKAs. Although both DOACs and VKAs increased the risk of bleeding, only VKAs were associated with higher ICH rates.

中文翻译：

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非高龄心房颤动患者的维生素 K 拮抗剂和直接口服抗凝剂

目的 在评估房颤 (AF) 患者口服抗凝剂的临床试验中，非高龄患者的代表性不足。本研究的目的是评估口服抗凝剂对 AF 年龄≥90 岁患者的预后影响。设计 非老年 AF 患者的回顾性多中心研究。地点和参与者 研究了 2013 年 1 月至 2018 年 12 月期间在西班牙 3 个卫生地区的 1750 名非瓣膜性 AF 住院和门诊患者。方法 根据抗血栓治疗将患者分为 3 组：非口服抗凝剂（30.5%）、维生素 K 拮抗剂（VKAs；28.6%）和直接口服抗凝剂（DOACs；40.9%）。在平均 23.6 ± 6.6 个月的随访期间，使用 Cox 回归分析评估疗效结果（死亡和栓塞事件），并通过竞争风险回归评估安全性结果（出血需要住院）。结果与倾向得分匹配分析相辅相成。结果 随访期间，988 例患者死亡（56.5%），180 例发生栓塞事件（10.3%），186 例发生大出血（10.6%）。多变量调整后，与非抗凝治疗相比，DOACs 与较低的死亡和栓塞事件风险相关 [风险比 (HR) 0.75，95% 置信区间 (CI)] 0.61-0.92)，但 VKAs 并非如此（HR 0.87，95% CI 0.72-1.05）。这些结果在倾向评分匹配分析后得到证实。对于出血，DOAC 和 VKA 均被证明与更高的风险相关（DOAC 的 HR 为 1.43；95% CI 0.97-2.13；VKA 的 HR 1.94；95% CI 1.31-2.88），尽管 DOAC 的结果没有统计学意义（P = .074）。对于颅内出血 (ICH)，只有 VKA 而非 DOAC 具有更高的 ICH 风险（HR 4.43；95% CI 1.48-13.31）。结论和意义 在非老年 AF 患者中，与非抗凝治疗相比，DOAC 可降低死亡率和栓塞事件。VKA 没有观察到这种减少。尽管 DOAC 和 VKA 都增加了出血风险，但只有 VKA 与较高的 ICH 发生率相关。VKA 没有观察到这种减少。尽管 DOACs 和 VKAs 都会增加出血风险，但只有 VKAs 与较高的 ICH 发生率相关。VKA 没有观察到这种减少。尽管 DOACs 和 VKAs 都会增加出血风险，但只有 VKAs 与较高的 ICH 发生率相关。