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Direct Oral Anticoagulants vs. Warfarin for Cerebral Venous Thrombosis
Quick Takes
- DOACs are comparable in efficacy to warfarin with less major hemorrhage in patients with cerebral venous thrombosis in a real-world analysis.
- Rates of partial or complete recanalization were high overall and similar regardless of anticoagulant strategy.
Study Questions:
Are direct oral anticoagulants (DOACs) as safe and effective as warfarin in preventing recurrence of venous thrombosis or cerebral venous thrombosis (CVT) in patients treated for CVT?
Methods:
ACTION-CVT (Anticoagulation in the Treatment of Cerebral Venous Thrombosis) was a multicenter, international, retrospective study of consecutive patients with CVT treated with oral anticoagulation from January 2015–December 2020. Diagnosis of CVT was confirmed by review of medical records and imaging studies. Patients not treated with oral anticoagulation or with indications for a specific anticoagulation strategy were excluded. Demographics, CVT risk factors, hypercoagulable labs, baseline imaging data, compliance with anticoagulant therapy, and clinical and radiological outcomes were abstracted from medical records. The primary outcome was recurrent venous thrombosis or CVT. Other outcomes included recanalization status on imaging, major hemorrhage, and death. An adjusted inverse probability of treatment-weighted Cox-regression model was used to compare the primary and safety outcomes, and logistic regression was used to compare recanalization rates.
Results:
Among 1,025 patients with CVT, 845 met criteria for inclusion. The mean age was 44.8 years and 65.7% were women. A DOAC was the sole anticoagulant used in 33% of patients, while 51.8% of patients received warfarin. Another 15.1% of patients received both treatments at different times. The most common DOAC used was apixaban (66.6%), followed by rivaroxaban (18.2%) and dabigatran (13.5%). The median time to follow-up was 345 (interquartile range, 140-720) days.
There were 5.68 recurrent venous thromboses, 3.77 major hemorrhages, and 1.84 deaths per 100 patient-years. Treatment with a DOAC was associated with a similar risk of recurrent venous thrombosis compared to warfarin (adjusted hazard ratio [aHR], 0.94; 95% confidence interval [CI], 0.51-1.73; p = 0.84), death (aHR, 0.78; 95% CI, 0.22-2.76; p = 0.70), and rate of partial/complete recanalization (aOR, 0.92; 95% CI, 0.48-1.73; p = 0.79). There was a lower risk of major hemorrhage in patients treated with a DOAC compared to those treated with warfarin (aHR, 0.35; 95% CI, 0.15-0.82; p = 0.02).
Conclusions:
This study found that in a real-world cohort of patients with CVT, treatment with a DOAC is associated with a similar risk of venous thrombosis recurrence, death, and recanalization rates but a lower risk of major hemorrhage when compared with warfarin.
Perspective:
Findings of this study are consistent with the RESPECT-CVT trial, a randomized trial comparing dabigatran to warfarin, as well as other small observational studies that suggest comparable outcomes with DOACs and warfarin. This study also showed a reduced risk of major hemorrhage with DOACs compared to warfarin, a finding consistent with data from non-CVT patient populations but not seen in prior CVT studies.
Clinical Topics: Anticoagulation Management, Noninvasive Imaging, Prevention, Vascular Medicine, Novel Agents
Keywords: Anticoagulants, Dabigatran, Diagnostic Imaging, Hemorrhage, Patient Care Team, Risk Factors, Rivaroxaban, Secondary Prevention, Stroke, Vascular Diseases, Venous Thrombosis, Warfarin
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