Illustration of human blood cells

Older adults with atrial fibrillation and prior stroke who are prescribed direct oral anticoagulants (DOACs) have better outcomes than those who take warfarin, a new study published in the Journal of the American Geriatrics Society found.

Investigators from the University of Tokyo examined healthcare data for more than 101,000 patients aged 75 years and older with atrial fibrillation who were hospitalized for stroke from January 2015 through March 2019. Readmission for stroke and bleeding events, including intracranial bleeding, was lower in the DOAC group when compared with the warfarin group. 

There was no difference between the groups for gastrointestinal bleeding, another potential risk factor with blood-thinning drugs.

Handle DOACs with care

In 2019, the American Heart Association and other groups recommended DOACs over warfarin for treatment of afib. DOACs have a relatively low risk of side effects and, unlike with warfarin, there is no need for blood test monitoring. Yet, despite their increasing popularity, there is still some debate about when and which DOAC is the best choice when compared to warfarin, the long-standing standard-of-care. 

When evidence is lacking for DOACs, warfarin may be the best option, one expert wrote in a recent article for the journal NEJM Evidence. DOACs should necessarily be used interchangeably, he warned.

“DOACs represent an excellent therapeutic option in clinical settings for which there are robust supporting data,” explained Pavan K. Bendapudi, M.D., of Massachusetts General Hospital and Harvard Medical School in Boston. “But caution must be exercised when utilizing these agents outside the very specific populations for which they were tested in randomized controlled trials.”

These populations may include patients with prosthetic heart valves, certain autoimmune conditions and significant renal dysfunction, Bendapudi wrote. The cost advantages of warfarin should also be part of joint decision-making between physician and patient, he added.   

Warfarin “remains the standard of care in several clinical scenarios and may be the preferred option whenever a clinician is uncertain,” he concluded.

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