For older patients with atrial fibrillation, the competing risks for death reduce the net clinical benefit (NCB) of oral anticoagulation, according to a study published online Nov. 11 in Circulation: Cardiovascular Quality and Outcomes to coincide with the annual meeting of the American Heart Association, held from Nov. 16 to 18 in Philadelphia.

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Sachin J. Shah, M.D., M.P.H., from the University of California in San Francisco, and colleagues estimated the lifetime NCB of warfarin and apixaban relative to no treatment in quality-adjusted life years (QALYs) among adults ≥75 years with incident atrial fibrillation. Minimum clinically relevant lifetime benefit was defined as 0.10 QALYs. The effect of competing risks for death on NCB was examined using two models, one including competing risks and one without competing risks. Data were included for 14,946 patients with a median age of 81 years.

The researchers found that NCB associated with warfarin decreased below 0.10 lifetime QALYs after age 87 years, while NCB associated with apixaban did not decrease below 0.10 lifetime QALYs until after age 92 years. Over a three-year period, removing competing risks for death resulted in a higher NCB in sensitivity analyses (at 90 years, median difference using warfarin and apixaban, 0.010 and 0.025 QALYs, respectively).

“Competing risk of death is an important consideration when estimating the net clinical benefit of anticoagulation therapy,” Shah said in a statement. “Failing to account for competing risks likely overestimates the net clinical benefit of anticoagulation.”

Several authors disclosed financial ties to the pharmaceutical industry.

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