Efficacy and safety of direct-acting oral anticoagulants compared to vitamin K antagonists in COVID-19 outpatients with cardiometabolic diseases

Abstract

Background It remains uncertain if prior use of oral anticoagulants (OACs) in COVID-19 outpatients with multimorbidity impacts prognosis, especially if cardiometabolic diseases are present. Clinical outcomes 30-days after COVID-19 diagnosis were compared between outpatients with cardiometabolic disease receiving vitamin K antagonist (VKA) or direct-acting OAC (DOAC) therapy at time of COVID-19 diagnosis. Methods A study was conducted using TriNetX, a global federated health research network. Adult outpatients with cardiometabolic disease (i.e. diabetes mellitus and any disease of the circulatory system) treated with VKAs or DOACs at time of COVID-19 diagnosis between 20-Jan-2020 and 15-Feb-2021 were included. Propensity score matching (PSM) was used to balance cohorts receiving VKAs and DOACs. The primary outcomes were all-cause mortality, intensive care unit (ICU) admission/mechanical ventilation (MV) necessity, intracranial haemorrhage (ICH)/gastrointestinal bleeding, and the composite of any arterial or venous thrombotic event(s) at 30-days after COVID-19 diagnosis. Results 2275 patients were included. After PSM, 1270 patients remained in the study (635 on VKAs; 635 on DOACs). VKA-treated patients had similar risks and 30-day event-free survival than patients on DOACs regarding all-cause mortality, ICU admission/MV necessity, and ICH/gastrointestinal bleeding. The risk of any arterial or venous thrombotic event was 43% higher in the VKA cohort (hazard ratio 1.43, 95% confidence interval 1.03–1.98; Log-Rank test p = 0.029). Conclusion In COVID-19 outpatients with cardiometabolic diseases, prior use of DOAC therapy compared to VKA therapy at the time of COVID-19 diagnosis demonstrated lower risk of arterial or venous thrombotic outcomes, without increasing the risk of bleeding.

Impact of the COVID-19 pandemic on cardiovascular heart disease medication use: time-series analysis of England’s prescription data during the COVID-19 pandemic (January 2019 to October 2020)

“…While we cannot be sure that the observed declining prescription coverage is directly the cause of mortality, we note that Wadhera et al . 58 demonstrate, in their recent study, that the incidence of patients’ diseases increased from 2019 to 2020 in the United States. They show an increase in deaths caused by ischemic heart disease and hypertensive diseases in regions of the United States during early 2020 (397,042 cardiovascular deaths from 1 January 2020 to 2 June 2020 with ratio of the relative change in deaths per 100,000 in 2020 versus 2019: 1.11, 95% confidence interval: 1.04–1.18) and lends credibility to a causal link.…”

“…Patient presentations are more likely to appear as escalating or uncontrolled BP and increased number of undiagnosed and diagnosed people with hypertension, which could be detected via BP screening. This trajectory is also supported by reduced use of warfarin and direct-acting oral anticoagulants (DOACs) during the pandemic, 24 , 58 , 59 which is different to the prior long-term trend and hopefully is temporary. The second- and third-order derivative outcomes because of such changes remain to be seen in the clinical data and wider epidemiological findings.…”

Atrial Fibrillation in the Setting of Acute Pneumonia: Not a Secondary Arrhythmia

“…Table 2 (Ref. [76][77][78][79][80][81][82]) summarizes the main characteristics of the most recent studies that analyzed the effects of COVID-19 on cardiovascular events and AF. At the beginning of this pandemic, Libby and Lüscher [83] published an interesting review in which they referred to COVID-19 as an "endothelial disease" strictly connected to inflammation.…”

“…It is noteworthy that COVID-19 disease is associated with a higher either arterial or venous thrombotic risk, which is important to keep in mind in the therapeutic management of these patients [92]. In this regard, in a cohort of outpatients with COVID-19 infection and cardiometabolic diseases it has been observed that the use of direct oral anticoagulants was associated with a lower rate of both arterial and venous thrombotic events as compared to vitamin K antagonists use [81,82].…”

Real world data on cardiometabolic diseases in U.S. adults during the SARS-CoV-2 pandemic: a decentralized registry study

“…Consequently, anti-coagulant use has been suggested in COVID-19 positive diabetics [ 18 ]. At the time of diagnosis of COVID-19 in patients with cardiometabolic diseases, prior use of oral anti-coagulants compared to Vitamin K antagonists demonstrated lower risk of arterial or venous thrombosis without increasing the risk of bleeding [ 19 ]. First-line treatment for stage I hypertension include angiotensin receptor blockers (ARBs) and angiotensin converting enzyme inhibitors (ACE-I) [ 20 ].…”