Key result
Direct oral anticoagulants were at least as effective as warfarin at reducing the risk of stroke and systemic embolism in elderly patients with atrial fibrillation, with rivaroxaban demonstrating an event rate of 2.29% compared to 2.85% for warfarin (HR 0.08).
Why the study?
Do direct oral anticoagulants reduce stroke, systemic embolism, and major bleeding compared to warfarin in elderly patients with atrial fibrillation?
Do direct oral anticoagulants reduce stroke, systemic embolism, and major bleeding compared to warfarin in elderly patients with atrial fibrillation?
Hazard Ratio: 0.08 (95% CI 0.63–1.02)
Absolute Event Rate: 2.29% vs 2.85%
Absolute Risk Reduction: 0.56%
Number Needed to Treat: 179
DOACs are effective alternatives to warfarin for stroke prevention in elderly patients with atrial fibrillation, offering lower intracranial bleeding risk but requiring careful agent and dose selection due to potentially higher gastrointestinal and major bleeding risks in the very elderly.
Supports DOAC preference over warfarin for stroke prevention in elderly AF with lower ICH; extends RCT evidence while flagging GI bleeding risk in those ≥80.
Direct oral anticoagulants (DOACs), previously also known as novel oral anticoagulants (NOACs), have increased the therapeutic options for stroke prevention in atrial fibrillation (AF). Previous studies comparing their relative efficacy and safety do not address age-related differences, such as comorbidities and physical and social boundaries. This review aimed to summarize and compare the clinical and safety outcomes of DOACs and warfarin for stroke prevention in AF in the elderly population (≥ 65 years). We searched PubMed for randomized controlled trials and meta-analyses that compared DOACs and warfarin in elderly patients with AF. Stroke and systemic embolism (SSE) and major bleeding (MB) were primary outcomes. Secondary outcomes included ischemic stroke, all-cause mortality, intracranial bleeding, and gastrointestinal bleeding. Of 66 studies identified, one randomized control trial (RCT) and one meta-analysis were included. DOACs were at least as effective at reducing the risk of SSE as warfarin. DOACs demonstrated a minimal benefit for ischemic stroke (dabigatran, 110 mg, relative risk (RR) 1.08; edoxaban, 60 mg, RR 1.00; and apixaban, 5 mg, RR 0.99). DOACs associated with decreased risk of MB relative to warfarin include dabigatran, 110 mg; apixaban, 5 mg; and edoxaban, 60 mg (RR 0.80, 0.70, and 0.80, respectively), while dabigatran, 150 mg, and rivaroxaban, 20 mg, increased risk (RR 0.79 - 0.83, respectively). Dabigatran, 110 mg and 150 mg doses, and edoxaban increased the risk of gastrointestinal bleeding (RR 1.04, 1.12, and 1.23, respectively). Lower rates of SSE and intracranial bleeding were seen with DOACs compared to warfarin. Dabigatran, 150 mg, and rivaroxaban, 20 mg, were associated with higher MB in older elderly compared to warfarin. DOACs may be attractive alternatives to warfarin, but further studies are needed to make clinical recommendations.
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Kailas et al. (2016) conducted a review in Atrial Fibrillation. Direct oral anticoagulants (DOACs) vs. Warfarin was evaluated on Stroke and systemic embolism (HR 0.08, 95% CI 0.63 - 1.02). Direct oral anticoagulants were at least as effective as warfarin at reducing the risk of stroke and systemic embolism in elderly patients with atrial fibrillation, with rivaroxaban demonstrating an event rate of 2.29% compared to 2.85% for warfarin (HR 0.08).
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