Key result
DOAC use linked to ~31% lower net adverse clinical events compared to warfarin.
Why the study?
Whether cerebral microbleeds and anemia identify older AF patients with narrower benefit-harm margins for DOACs versus warfarin remains uncertain.
Does DOAC therapy improve 2-year net clinical benefit compared to warfarin in older adults with non-valvular atrial fibrillation and varying cerebral microbleed/anemia profiles?
Cohort (n=797)
No
Does DOAC therapy improve 2-year net clinical benefit compared to warfarin in older adults with non-valvular atrial fibrillation and varying cerebral microbleed/anemia profiles?
Hazard Ratio: 0.69 (95% CI 0.52–0.91)
Absolute Event Rate: 14.9% vs 21.8%
p-value: p=0.009
DOACs provide a favorable 2-year estimated net clinical benefit compared to warfarin in older adults with non-valvular AF, although this benefit margin narrows in patients with concurrent cerebral microbleeds and anemia.
Supports DOAC preference in older nonvalvular AF; extends RCTs with net-benefit estimates stratified by microbleeds and anemia but leaves confirmation open.
Background: Randomized trials favor direct oral anticoagulants (DOACs) over warfarin for eligible atrial fibrillation (AF), but whether cerebral microbleeds (CMBs) and anemia identify older patients with narrower benefit-harm margins remain uncertain. We estimated 2-year net clinical benefit (NCB) overall and by CMB/anemia strata. Methods: This single-center, MRI-selected prospective observational cohort included patients aged ≥65 years with non-valvular AF receiving a DOAC or warfarin. Follow-up began at susceptibility MRI; CMB presence (0 vs ≥1) was rated by two blinded raters, and anemia used World Health Organization hemoglobin thresholds. DOAC-warfarin associations were estimated using propensity-score overlap weighting and competing-risk models for ischemic stroke/systemic embolism (IS/SE) and intracranial hemorrhage (ICH). Two-year NCB was expressed as net events prevented per 1000 with bootstrap 95% confidence intervals (CIs). Results: Among 797 patients (DOAC n=517; warfarin n=280), 31.0% had ≥1 CMB and 33.8% had anemia. During 2463 person-years, 40 first IS/SE events, 22 first ICH events, and 89 deaths occurred as first components of net adverse clinical events (NACE). After weighting, DOAC use was associated with lower NACE (2-year risk 14.9% vs 21.8%; hazard ratio 0.69, 95% CI 0.52-0.91), ICH (1.4% vs 4.3%; subdistribution hazard ratio 0.39, 95% CI 0.21-0.72), and IS/SE (3.9% vs 6.4%; subdistribution hazard ratio 0.63, 95% CI 0.41-0.96). Estimated NCB favored DOACs overall (67.0/1,000; 95% CI 28.4-102.7) and was attenuated in patients with both CMBs and anemia (38.0/1,000; 95% CI 4.2-71.5). Conclusions: DOAC use was associated with a favorable estimated 2-year NCB vs warfarin in this MRI-selected cohort. Combined CMB/anemia findings are exploratory and hypothesis-generating and should not guide prescribing without multicenter validation.
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Ma et al. (2026) conducted a cohort in Non-valvular atrial fibrillation (n=797). Direct oral anticoagulants (DOAC) vs. Warfarin was evaluated on Net adverse clinical events (NACE), defined as the first occurrence of ischemic stroke/systemic embolism, intracranial hemorrhage, or death (HR 0.69, 95% CI 0.52-0.91, p=0.009). DOAC use was associated with a 31% reduction in net adverse clinical events (HR 0.69) and yielded a favorable estimated 2-year net clinical benefit of 67.0 events prevented per 1,000 patients compared to warfarin.
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