DOAC Safety, Efficacy Similar to Warfarin for Nonvalvular Atrial Fibrillation

Prescription bottles, medicine
Prescription bottles, medicine
The currently available DOACS are at least as effective and safe as warfarin for patients with nonvalvular atrial fibrillation.

Direct-acting oral anticoagulants (DOACs) are at least as effective and safe as warfarin for the prevention of thromboembolic events and bleeding complications in patients with nonvalvular atrial fibrillation (AF), according to a study recently published in the Annals of Internal Medicine.

Limited knowledge is available about the relative efficacy and safety of interventions to prevent thromboembolic events in patients with AF. To explore this issue, investigators completed a systematic review of 220 studies that examined thromboembolic or bleeding complications in adults with nonvalvular AF. 

The included studies enrolled at least 20 patients aged 18 years or older with nonvalvular AF who received anticoagulation, antiplatelet, or procedural therapy. All studies had an active comparator and assessed an outcome of interest. 

Based on this systematic review, investigators found that dabigatran and apixaban were better than warfarin, and rivaroxaban and edoxaban were similar to warfarin in preventing stroke or systematic embolism.

Additionally, apixaban and edoxaban were better than warfarin, and rivaroxaban and dabigatran were similar to warfarin in reducing the risk for major bleeding.

Dabigatran effects were similar in patients with renal dysfunction (>.05). Patients younger than 75 years had lower bleeding rates on dabigatran (<.001).

Apixaban consistently reduced the risk of stroke, systematic embolism, and major bleeding across many subgroups including renal impairment, diabetes, and prior stroke (>.05 for all).

Bleeding risk reduction was greatest in patients with glomerular filtration rates less than 50 mL/min/1.73 m2 (=.003). In addition, rivaroxaban and edoxaban exhibited similar treatment effects in subgroups with prior stroke, diabetes, or heart failure (>.05 for all).

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Limitations of this investigation included heterogeneous study populations, interventions, and outcomes. 

Additional interventions for atrial fibrillation exist, including left atrial appendage closure devices. Further research is necessary to understand the efficacy and safety of such interventions compared with DOACs and warfarin.  

Disclosures: Several study authors reported financial ties to pharmaceutical industry. Please refer to original study for full list of disclosures.


Lowenstern A, Al-Khatib SM, Sharan L, et al. Interventions for preventing thromboembolic events in patients with atrial fibrillation [published online October 30, 2018]. Ann Intern Med. doi: 10.7326/M18-1523