Background Obstructive
sleep apnea (OSA) is associated with an increased incidence of
atrial fibrillation (AF),
hypertension, diabetes,
heart failure,
coronary heart disease,
stroke, and death. We sought to evaluate the effectiveness and safety of
rivaroxaban versus
warfarin in nonvalvular AF (NVAF) patients with concomitant OSA. Methods This was an analysis of electronic health record (EHR) data from November 2010 to December 2021. We included adults with NVAF and OSA at baseline, newly initiated on
rivaroxaban or
warfarin, and with ≥12 months of prior EHR activity. Patients with valvular disease, alternative indications for oral anticoagulation, or who were pregnant were excluded. The incidence rates of developing
stroke or systemic
embolism (SSE) and
bleeding-related hospitalization were evaluated. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using propensity score-overlap weighted proportional hazards regression. Multiple sensitivity and subgroup analyses were performed. Results We included 21,940
rivaroxaban (20.1% at the 15 mg dose) and 38,213
warfarin (time-in-therapeutic range = 47.3 ± 28.3%) patients.
Rivaroxaban was found to have similar hazard of SSE compared to
warfarin (HR = 0.92, 95% CI = 0.82-1.03).
Rivaroxaban was associated with a reduced rate of
bleeding-related hospitalizations (HR = 0.85, 95% CI = 0.78-0.92) versus
warfarin, as well as reductions in intracranial (HR = 0.76, 95% CI = 0.62-0.94) and extracranial (HR = 0.89, 95%CI = 0.81-0.97)
bleeding. Upon sensitivity analysis restricting the population to men with a CHA 2 DS 2 VASc score ≥2 or women with a score ≥3,
rivaroxaban was associated with a significant 33% risk reduction in SSE and 43% reduction in the risk of
bleeding-related hospitalization. No significant interaction for the SSE or
bleeding-related hospitalization outcomes was observed upon subgroup analyses. Conclusion Among patients with NVAF and OSA,
rivaroxaban had similar SSE risk versus
warfarin but was associated with reductions in any intracranial and extracranial
bleeding-related hospitalizations.
Rivaroxaban was associated with significant reductions in SSE and
bleeding-related hospitalizations when the study population was restricted to patients with a moderate-to-high risk of SSE. These data should provide prescribers with additional confidence in selecting
rivaroxaban in NVAF patients who have OSA at the time of anticoagulation initiation.