Systemic anticoagulation improves quality-adjusted life years (QALYs) among patients with idiopathic pulmonary arterial hypertension (PAH), a decision analysis in Pulmonology Circulation suggests.
However, researchers also found that in a model of patients with connective tissue disease-associated PAH (CTD-PAH), anticoagulation with vitamin K antagonists (VKAs) may worsen quality-adjusted survival.
A 31-state Markov simulation decision analytic model was used to examine outcomes associated with anticoagulation with VKA therapy vs no anticoagulation with VKA therapy in a model of patients with PAH. Patients could develop atrial fibrillation, stroke, deep vein thrombosis, or bleeding during each 1-month cycle in the simulation. The model included several different patient characteristics in the analysis, including sex, use of central catheter-based PAH therapy, type of PAH (eg, idiopathic or CTD-PAH), and use of oral contraceptive medication among women.
All cases of idiopathic PAH favored anticoagulation with VKAs, as represented by a gain of 0.43 to 0.51 QALY. Conversely, anticoagulation was considered detrimental in all cases of CTD-PAH, as indicated by a loss of 0.66 to 1.89 QALYs. For anticoagulation to be better favored in cases of CTD-PAH, the researchers suggest that the therapy would need a hazard ratio for PAH mortality of ≥0.95.
According to probabilistic sensitivity analyses of CTD-PAH in both women and men, the choice to not use anticoagulation was favored in 95.5% to 99.0% of 10,000 second-order Monte Carlo iterations, whereas anticoagulation was favored in 75.7% to 79.5% of simulations in men with idiopathic PAH and 97.0% to 98.3% of simulations in women with idiopathic PAH.
A limitation of the study included the modeling of only the effects of VKAs rather than other frequently used anticoagulation therapies.
The finding that systemic anticoagulation with VKA is beneficial for improving quality of life and outcomes in patients with idiopathic PAH provides “the basis of future shared decision-making tools for clinical use in determining PAH therapeutic strategies at the bedside.”
Jose A, Eckman MH, Elwing JM. Anticoagulation in pulmonary arterial hypertension: a decision analysis. Pulm Circ. 2019;9(4):1-12.