The following is a summary of “Efficacy and Safety of Direct Oral Anticoagulants for Stroke Prevention in Older Patients With Atrial Fibrillation: A Network Meta‐Analysis of Randomized Controlled Trials,” published in the November 2023 issue of Cardiology by Lin et al.

In the realm of treating older patients facing atrial fibrillation and the accompanying risk of thromboembolic and bleeding incidents, the most effective treatment strategy remains unclear. This comprehensive meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Their search across PubMed, EMBASE, and Cochrane databases targeted randomized controlled trials comparing thromboembolic or bleeding outcomes between direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) specifically in individuals aged ≥75 years with atrial fibrillation. The primary efficacy endpoint assessed the composite of stroke and systemic embolism, while safety endpoints encompassed major bleeding, any clinically relevant bleeding, and intracranial hemorrhage. 

Each DOAC and VKA underwent pairwise comparison in a network meta-analysis. Further assessments compared high- and low-dose regimens and factor IIa and Xa inhibitors. Seven randomized controlled trials were included in this analysis. Results revealed no significant differences in stroke and systemic embolism risks among DOACs. Similarly, major bleeding did not significantly differ between each DOAC and VKA. However, the risk of intracranial hemorrhage was notably lower with dabigatran, apixaban, and edoxaban compared to VKA and rivaroxaban, which exhibited similar risks. High-dose regimens displayed reduced risks of stroke or systemic embolism compared to VKA, with both high and low doses showing comparable bleeding risks.

In summary, among individuals aged ≥75 years confronting atrial fibrillation, DOACs demonstrated a lower incidence of thromboembolic events in contrast to VKA. Moreover, dabigatran, apixaban, and edoxaban were linked to reduced risks of intracranial hemorrhage compared to VKA and rivaroxaban. These findings emphasize the potential benefits of DOACs, particularly certain formulations, in this elderly patient population managing atrial fibrillation.

Source: ahajournals.org/doi/10.1161/JAHA.123.030380