Int J Arrhythm.  2021 Mar;22(1):4. 10.1186/s42444-021-00032-0.

Risk for osteoporotic fractures in patients with atrial fibrillation using different oral anticoagulants

  • 1Division of Cardiology, Department of Internal Medicine, Severance Car‑ diovascular Hospital, Yonsei University College of Medicine, 50‑1 Yonseiro, Seodaemun‑gu, Seoul 03722, Republic of Korea
  • 2Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea.
  • 3Liverpool Centre for Cardiovascular Science, University of Liverpool and Liver‑ pool Heart and Chest Hospital, Liverpool, UK.


We aimed to investigate the comparative risk of fracture among patients with atrial fibrillation (AF) treated with warfarin or non-vitamin K antagonist oral anticoagulants (NOACs).
Using the Korean National Health Insurance Service database, patients with AF who received a prescrip‑ tion for apixaban, dabigatran, rivaroxaban, or warfarin between 2013 and 2016 were included. Risk of major fractures (osteoporotic hip, vertebral, or pelvic fractures) were compared using inverse probability of treatment weighting.
There were 70,481 patients identified (41.3% women; mean [SD] age 70.5 [11.3] years); 16,992 apixaban, 22,514 dabigatran, 27,998 rivaroxaban, and 29,390 warfarin users. During a median follow-up of 390 days, 2412 major fractures occurred with weighted incidences per 100 patient-years of 2.56 for apixaban, 2.39 for dabigatran, 2.78 for rivaroxaban, and 3.43 for warfarin. NOAC use was associated with a lower risk for fracture than warfarin use: HR 0.70 (95% confidence interval [CI] 0.57–0.86) for apixaban, HR 0.69 (95% CI 0.60–0.78) for dabigatran, and HR 0.79 (95% CI 0.70–0.90) for rivaroxaban. In head-to-head comparisons between NOACs, there was no significant difference between apixaban and dabigatran. Rivaroxaban was associated with a higher risk for fracture than dabigatran (HR 1.15, 95% CI 1.02–1.31).
In patients with AF, NOAC use may result in a lower risk for osteoporotic fracture compared with warfa‑ rin use. Fracture risk does not seem to be altered by the choice of NOAC type, except for rivaroxaban. These associa‑ tions may help inform benefit–risk assessments when choosing between the different anticoagulant types.


Atrial fibrillation; Osteoporosis; Fracture; Oral anticoagulant
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