DOAC is better than warfarin in preventing stroke in patients with valvular atrial fibrillation

This article comes from NEJM Journal Watch DOACs Are Effective for Stroke Prevention in Valvular AFDOAC can effectively prevent stroke in patients with valvular atrial fibrillation.
Comment by Mark S.
Link, MD In a population-based cohort study, oral direct Anticoagulant (DOAC) is superior to warfarin in terms of efficacy and safety.

Early randomized controlled trials comparing DOAC and warfarin in the treatment of atrial fibrillation excluded patients with valvular heart disease.

However, later trials included more patients with valvular atrial fibrillation, and recent studies only excluded patients with mechanical valves and moderate to severe mitral stenosis.

The researchers analyzed a large commercial database to compare the effects of DOAC and warfarin in 56,336 patients with valvular atrial fibrillation with matching propensity scores and outcomes.

Patients who had undergone valve replacement surgery (whether mechanical or biological) were excluded.

The median follow-up time was shorter: 134 days for DOAC and 124 days for warfarin.

The risks of ischemic stroke and systemic embolism (hazard ratio, 0.
64) and major hemorrhage (hazard ratio, 0.
67) in the DOAC group were lower than those in the warfarin group.

In an analysis based on specific drugs, the safety and efficacy outcomes of apixaban and rivaroxaban were similar to the overall DOAC outcome, but dabigatran was significantly better than warfarin in terms of major bleeding.

Commenting on these real-world results confirms the positive DOAC results reported by the randomized controlled study.

However, these results did not extend the scope of DOAC medication to moderate to severe mitral stenosis, because the number of such patients is too small for meaningful analysis.

These results also did not extend the scope of DOAC medication to patients with biological or mechanical valves.

Residual confounding factors (that is, there may be an unmeasured difference between the doctor who prescribes DOAC and the patient who prescribes warfarin) may also have an impact.

In the final analysis, more and more data show that DOAC can effectively treat patients with autologous valvular disease (except for mitral stenosis).

Dawwas GK et al.
Effectiveness and safety of direct oral anticoagulants versus warfarin in patients with valvular atrial fibrillation: A population-based cohort study.
Ann Intern Med 2021 Mar 30; [e-pub].
(https://doi .
org/10.
7326/M20-6194) Related reading NEJM Journal Watch The NEJM Journal Watch is published by NEJM Group.
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