Oral Anticoagulants and Antiplatelet Agents in Atrial Fibrillation Patients with Concomitant Critical Limb Ischemia: A nationwide cohort study

Abstract Background Evidences of clinical outcomes for oral anticoagulants and antiplatelet treatment (APT) in atrial fibrillation (AF) patients with critical limb ischemia (CLI) are very limited. Methods In this nationwide retrospective cohort study collected from Taiwan National Health Insurance Research Database, 1,223 AF patients with CLI taking DOACs, warfarin, or APT were identified from June 1, 2012, to December 31, 2017. We used propensity score stabilized weighting (PSSW) to balance covariates across study groups. Results After PSSW, DOAC (n=446) was associated with lower risks of ischemic stroke/systemic embolism (IS/SE), all major adverse limb events, and all major bleeding events when comparing with warfarin (n=237). DOAC was associated with lower risks of IS/SE, acute myocardial infarction (AMI), and all major adverse limb events and a comparable risk of major bleeding events when comparing with APT (n=540). DOAC has a lower risk of composite net-clinical-benefit outcome (IS/SE, AMI, all major adverse limb events, plus all major bleeding events) when compared with warfarin (hazard ratio (HR):0.48; 95% confidence interval (CI):0.35–0.65; P 75 years old, presence of diabetes mellitus, or chronic kidney disease. Conclusions DOAC was associated with a significantly lower risk of composite net-clinical-benefit outcome than either warfarin or APT in AF patients with concomitant CLI. Further prospective study is necessary to validate the findings in the future.