DOACs safer than warfarin in patients with cerebral venous thrombosis
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In patients with cerebral venous thrombosis, direct oral anticoagulants were safer than warfarin without compromising efficacy, researchers reported at the International Stroke Conference.
Shadi Yaghi, MD, associate professor of neurology and vascular neurology division chief at The Warren Alpert Medical School at Brown University, and colleagues conducted the retrospective observational ACTION-CVT study, simultaneously published in Stroke, to determine whether direct oral anticoagulants (DOACs) could be a reasonable alternative to warfarin in patients with cerebral venous thrombosis.
Among the cohort of 845 patients (mean age, 45 years; 65% women) treated for cerebral venous thrombosis from 2015 to 2020, 33% received a DOAC only, 51.8% received warfarin only and 15.1% received both at different times, Yaghi said at a press conference.
“We excluded subgroups where one treatment was preferred or contraindicated,” he said. “All outcomes were only considered if they occurred while on oral anticoagulation. Patients who were switched from one treatment to another were considered as crossovers.”
During a median follow-up of 345 days, there were 5.68 recurrent venous thrombosis events per 100 patient-years, 3.77 major hemorrhages per 100 patient-years and 1.84 deaths per 100 patient-years, according to the researchers.
Among the 525 patients who could be analyzed for recanalization, 37% had complete, 48% had partial and 15% had none, Yaghi said at the press conference.
In adjusted inverse probability of treatment weighted models, compared with warfarin, DOAC treatment was associated with similar risk for recurrent venous thrombosis (adjusted HR = 0.94; 95% CI, 0.51-1.73; P = .84), risk for death (aHR = 0.78; 95% CI, 0.22-2.76; P = .7) and rate of partial or complete recanalization (aOR = 0.92; 95% CI, 0.48-1.73; P = .79), Yaghi and colleagues found.
However, Yaghi said, DOACs were associated with lower risk for major hemorrhage compared with warfarin (aHR = 0.35; 95% CI, 0.15-0.82; P = .02).
Propensity-score matching did not change the results, nor did sensitivity analyses, he said.
“Our findings need confirmation by ongoing large prospective studies or randomized trials,” Yaghi said at the press conference.
The study “confirms what we know in general of DOACs vs. warfarin, whether it’s in our own field of anticoagulation for atrial fibrillation or stroke prevention, or the experience we have with thromboembolic disease in general: We see that DOACs are similar in efficacy with a better safety profile,” Tudor G. Jovin, MD, FAHA, chairman and chief of neurology at Cooper University Health Care in Camden, New Jersey, and medical director of Cooper Neurological Institute, said in a discussion at the press conference. “It’s a great step forward. We were reluctant, mainly reflected in the fact that only 30% of patients received DOACs, despite them being widely available during this time. This has the potential to change practice.”
Reference:
Perspective
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Larry B. Goldstein, MD, FAAN, FANA, FAHA
Anticoagulation has been part of usual care for patients with central venous thrombosis for many years, although adequate data from prospective randomized trials are lacking, due in part to the relative rarity of the condition. The duration of anticoagulation is guided by the underlying cause.
This is a retrospective study with all of the inherent limitations of this study design (including the effects of unmeasured factors, in part addressed through the statistical analysis). The primary finding is that the effectiveness of an anticoagulation strategy with a direct oral anticoagulant was similar to warfarin with an apparent lower risk for major hemorrhage.
As the authors point out, a prospective randomized trial is needed; however, the results are encouraging. There is a tradeoff in ease of use and cost between direct oral anticoagulants and warfarin.
The report did not include assessment of functional outcomes, which are particularly important in these types of treatment.
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Yaghi S, et al. LB5. Presented at: International Stroke Conference; Feb. 9-11, 2022; New Orleans (hybrid meeting).
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