Journal of Thrombosis and Thrombolysis

, Volume 48, Issue 3, pp 366–372 | Cite as

Safety and effectiveness of oral factor Xa inhibitors versus warfarin in nonvalvular atrial fibrillation patients at high-risk for falls

  • Benjamin Miao
  • Mark J. Alberts
  • Thomas J. Bunz
  • Craig I. ColemanEmail author


Prescribers’ concern regarding falls resulting in intracranial hemorrhage is often cited as a justification for under-utilization of oral anticoagulation. We evaluated the safety and effectiveness of oral factor Xa inhibitors versus warfarin in nonvalvular atrial fibrillation patients at high-risk for falls. Using MarketScan claims from 11/2012-3/2017, we identified adult, oral anticoagulation-naïve, new-initiators of oral factor Xa inhibitors or warfarin with nonvalvular atrial fibrillation, ≥ 12 months of insurance coverage prior to starting oral anticoagulation and a predicted 2-year risk of falls ≥ 15%. Differences in baseline covariates between cohorts were balanced using inverse probability-of-treatment weights based on propensity scores. Hazard ratios (HRs) and 95% confidence intervals (CIs) for intracranial hemorrhage and stroke or systemic embolism were estimated. Among 25,144 nonvalvular atrial fibrillation patients at high-risk for falls (observed fall rate = 11.8%/person-year), oral factor Xa inhibitor use was associated with a 43% (95% CI = 5–65%) reduced hazard of intracranial hemorrhage compared to warfarin. Oral factor Xa inhibitors did not significantly reduce the hazard of stroke or systemic embolism versus warfarin (HR = 0.86, 95% CI = 0.66–1.11). Findings for the intracranial hemorrhage and stroke or systemic embolism endpoints were similar when apixaban and rivaroxaban were evaluated separately versus warfarin (p-interaction ≥ 0.64 for all). Oral factor Xa inhibitors reduced patients’ risk of intracranial hemorrhage and were at least as effective in preventing stroke or systemic embolism as warfarin in nonvalvular atrial fibrillation patients at high-risk for falls.


Anticoagulants Atrial fibrillation Fall risk Factor Xa inhibitor Intracranial hemorrhage Systemic embolism 



This study was funded by Bayer AG, Berlin, Germany

Compliance with ethical standards

Conflicts of interest

CIC has received Grant funding and consultancy fees from Janssen Scientific Affairs, LLC; Bayer Pharma AG; and Boehringer-Ingelheim Pharmaceuticals, Inc. MJA has received consultancy fees and honoraria from and is on the speakers bureau of Genentech, Janssen Pharmaceuticals, Boehringer Ingelheim, Pfizer, Bristol-Myers Squibb, and Medscape; consultancy fees and honoraria from Nestle, Daiichi Sankyo and Portola; honoraria from and is on the speakers bureau of Chiesi USA, Inc.; and patents/royalties from Duke University. No other authors have conflicts germane to this manuscript.

Supplementary material

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Electronic supplementary material 1 (DOCX 89 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Pharmacy Practice and Evidence-Based Practice CenterUniversity of Connecticut School of PharmacyStorrsUSA
  2. 2.Department of Neurology, Hartford HospitalHartfordUSA
  3. 3.Pharmacoepidemiology GroupNew England Health Analytics LLCGranbyUSA

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