Novel oral anticoagulant vs. warfarin in elderly atrial fibrillation patients with normal, mid-range, and reduced left ventricular ejection fraction

Aims: Patients with concomitant atrial fibrillation (AF) and reduced left ventricular ejection fraction (LVEF) have poor prognosis. Outcomes of novel oral anticoagulant (NOAC) in elderly AF patients with normal, mid-range, and reduced LVEF were investigated. Methods and results: Data were retrieved from Chang Gung Research Database during 2010–2017 for patients with AF. We excluded patients with venous thromboembolism within 6 months, total knee/hip replacement and heart valve replacement within 6 months, end-stage renal disease, stroke/systemic embolism (SE)/death within 7 days, age '65 years old, or no records of LVEF. Primary outcomes were ischaemic stroke (IS)/SE, major bleeding, and death from any cause. There was a total of 50 035 elderly AF patients retrieved. After exclusion criteria, 9615 patients with normal LVEF ≥ 50%, 737 with mid-range LVEF 41–49%, and 908 with reduced LVEF ≤ 40% were studied. At end of follow-up, patients on NOAC had significantly reduced IS/SE compared with warfarin in LVEF ≥ 50% [adjusted hazard ration (aHR) 0.80, 95% confidence interval (CI) 0.71–0.89] and LVEF 41–49% (aHR 0.57, 95% CI 0.36–0.88) after adjusting for covariates, while there was no difference in LVEF ≤ 40%. Patients on NOAC had significantly reduced major bleeding in all LVEF groups. In addition, patients on NOAC had significantly reduced death compared with warfarin in LVEF ≥ 50% (aHR 0.81, 95% CI 0.67–0.98). Conclusions: In elderly AF patients ≥65 years, using NOAC was associated with lower IS/SE compared with warfarin in normal and mid-range LVEF but not in reduced LVEF. Using NOACs was associated with lower death compared with warfarin in normal LVEF.