CC BY 4.0 · TH Open 2023; 07(01): e82-e93
DOI: 10.1055/a-2013-3346
Original Article

Effectiveness and Safety of Rivaroxaban Versus Warfarin among Nonvalvular Atrial Fibrillation Patients with Concomitant Obstructive Sleep Apnea

Nitesh Sood
1   Arrhythmia Services, Southcoast Health, Massachusetts, United States
Veronica Ashton
2   Real World Value and Evidence, Janssen Scientific Affairs LLC, Titusville, New Jersey, United States
Youssef Bessada
3   University of Connecticut School of Pharmacy, Connecticut, United States
Katelyn Galli
3   University of Connecticut School of Pharmacy, Connecticut, United States
Brahim K. Bookhart
2   Real World Value and Evidence, Janssen Scientific Affairs LLC, Titusville, New Jersey, United States
3   University of Connecticut School of Pharmacy, Connecticut, United States
4   Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut, United States
› Author Affiliations
Funding This study was supported by funding from Janssen Scientific Affairs, LLC, Titusville, NJ, United States.


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 CHA2DS2VASc 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.

Publication History

Received: 19 December 2022

Accepted: 10 January 2023

Accepted Manuscript online:
14 January 2023

Article published online:
29 March 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (

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