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Thromb Haemost 2024; 124(01): 069-079
DOI: 10.1055/s-0043-1772773
Stroke, Systemic or Venous Thromboembolism

Non-vitamin K Antagonist Oral Anticoagulant, Warfarin, and ABC Pathway Adherence on Hierarchical Outcomes: Win Ratio Analysis of the COOL-AF Registry

Sukrit Treewaree 
1   Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
,
Gregory Y. H. Lip    *
2   Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
3   Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
,
Rungroj Krittayaphong   *
1   Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
› Author Affiliations Funding This study was funded by a grant from the Health System Research Institute (grant number 59–053), and the Heart Association of Thailand under the Royal Patronage of H.M. the King. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Abstract

Background Atrial fibrillation (AF) Better Care (ABC) pathway adherence is associated with improved outcomes. Clinical trials have shown that non-vitamin K antagonist oral anticoagulants (NOACs) are as least as effective as warfarin for stroke prevention in AF patients. The Win Ratio method, analyzing hierarchical composite outcomes considering event timing and severity, has limited data on its use in Asians.

Objectives We aim to apply Win Ratio in a registry to access the comparative effectiveness of NOACs versus warfarin and ABC adherence versus nonadherence in Asian patients with AF.

Methods Our study included nonvalvular AF patients from the nationwide prospective COOL-AF registry in Thailand. The NOAC-treated group was compared with the warfarin-treated group using the Win Ratio, with the following order: all-cause death, intracranial hemorrhage (ICH), ischemic stroke/transient ischemic attack/systemic embolism, non-ICH major bleeding, and myocardial infarction or heart failure. ABC pathway adherence versus nonadherence was also compared. A Win Ratio greater than 1.00 indicating a better outcome.

Results The analysis included 2,568 patients, with 228 in the NOAC group and 2,340 in the warfarin group. The NOAC group had more wins than the warfarin group, with an unmatched Win Ratio of 1.64 (95% confidence interval [CI]: 1.22–2.20; p < 0.001). When compared with nonadherence, ABC pathway adherence was associated with a Win Ratio of 1.57 (95% CI: 1.33–1.85; p < 0.001).

Conclusion This Win Ratio analysis demonstrates the significant benefits of NOACs over warfarin and ABC pathway adherence over nonadherence in reducing the composite outcome in patients with AF.

Keywords

hierarchical composite outcome - atrial fibrillation - anticoagulants - ABC pathway - thrombosis

Data Availability Statement

The data used in this analysis are available from the corresponding author upon reasonable request.


Authors' Contribution

All authors made substantial contributions to conception and design, data interpretation, and revising the manuscript critically for important intellectual content. S.T. and R.K. made contributions to drafting and acquisition of data. S.T. made contributions to data analysis and figure drawing. All authors approved the final version to be published and agree to be accountable for all aspects of the work.


* Joint corresponding authors.


The review process for this paper was fully handled by Christian Weber, Editor in Chief.


Supplementary Material



Publication History

Received: 27 June 2023

Accepted: 27 July 2023

Article published online:
25 August 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
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