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Patient Evidence Summary
Doctor, I am over the age of 75 and have atrial fibrillation. Which anticoagulant should I take to prevent stroke?
In people over 75 years old with atrial fibrillation, direct oral anticoagulants (DOACs) are more effective than warfarin at preventing stroke or systemic embolization and are less likely to cause intracranial hemorrhage. However, these studies did not include people with heart valve problems, advanced kidney disease or liver disease.
Study highlights
People taking a DOAC were 24% less likely to have a stroke or systemic embolization compared to those taking warfarin.
People taking a DOAC were 52% less likely to have an intracranial hemorrhage compared to those taking warfarin.
Major bleeding did not differ for people taking a DOAC compared with those taking warfarin.
Understanding the problem
Atrial fibrillation is an abnormal heart rhythm that results in an irregular heartbeat. It is caused by abnormal electrical conduction within the small upper chambers of the heart. As a result, blood clots can form within these chambers and travel to the brain (causing a stroke) or elsewhere in the body (causing systemic embolization). Doctors recommend that most older people with atrial fibrillation take an anticoagulant to reduce their risk of stroke or systemic embolization.
Several large randomized controlled trials have shown that DOACs are as safe and effective as warfarin, an older blood thinner, for individuals with atrial fibrillation. However, these studies did not focus specifically on older individuals, and they did not compare the efficacy and safety of individual DOACs against one another.
Researchers conducted this systematic review to understand how DOACs compare to warfarin for older people with atrial fibrillation and determine whether one specific DOAC is safer or more effective than the others.
A summary of 5 studies published up to December 12, 2018.
Who? The studies included 27,639 people over the age of 75 with atrial fibrillation not related to problems with their heart valves.
What? The studies compared DOACs with warfarin.
DOACs | vs | Warfarin |
|---|---|---|
Eliquis® 2.5 mg twice a day or 5 mg twice a day Pradaxa® 110 mg twice a day or 150 mg twice a day Xarelto® 15 mg once a day or 20 mg once a day Lixiana® 30 mg once a day or 60 mg once a day | Warfarin adjusted to maintain a target INR between 2 and 3 |
DOACs vs warfarin in people over 75 years old with atrial fibrillation (average age 79 years; 58% male)
Outcomes | Results | Number of studies and quality of the evidence |
|---|---|---|
Stroke or systemic embolization | 24% fewer people had stroke or systemic embolization while taking a DOAC compared to those taking warfarin. In other words, 76 people had a stroke or systemic embolization while taking a DOAC for every 100 people who had a stroke or systemic embolization while taking warfarin. | 5 studies High-quality evidence |
Intracranial hemorrhage | 52% fewer people had an intracranial hemorrhage while taking a DOAC compared to those taking warfarin. In other words, 48 people had an intracranial hemorrhage while taking a DOAC for every 100 people who had an intracranial hemorrhage while taking warfarin. | 5 studies High-quality evidence |
| Major bleeding | No difference in major bleeding between DOACs and warfarin. | 5 studies High-quality evidence |
This Evidence Summary is based on the following article:
Malik AH, Yandrapalli S, Aronow WS, et al. Meta-Analysis of Direct-Acting Oral Anticoagulants Compared With Warfarin in Patients >75 Years of Age. Am J Cardiol. 2019 Jun 15;123(12):2051-2057. doi: 10.1016/j.amjcard.2019.02.060. Epub 2019 Mar 18. PubMed
Siraj Mithoowani, MD, FRCPC
Siraj completed his Internal Medicine and Hematology residency at McMaster University and is now pursuing additional training in Thrombosis as a CanVECTOR fellow. He also is a graduate student from the School of Health Professions Education at Maastricht University, Netherlands. Siraj hopes to combine his clinical and educational interests to develop new and innovative ways to teach patients and healthcare professionals about thromboembolism.
Lori-Ann Linkins, MD, MSc (Clin Epi), FRCPC
Dr. Linkins is an Associate Professor of Medicine (thrombosis) at McMaster University in Hamilton, Canada. She holds a Masters Degree in Health Research Methodology and is a Deputy Editor with the Health Information Research Unit, McMaster. Her research interests include heparin-induced thrombocytopenia and cancer-associated thrombosis. She was editor of the ACCP Guidelines, 9th Edition HIT chapter and is currently a member of the ASH VTE Guidelines HIT Panel.
Published: Tuesday, July 30, 2019
Last Updated: Thursday, July 30, 2020
Please note that the information contained herein is not to be interpreted as an alternative to medical advice from a professional healthcare provider. If you have any questions about any medical matter, you should consult your professional healthcare providers, and should never delay seeking medical advice, disregard medical advice or discontinue medication based on information provided here.
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, McMaster University