Warfarin faring better: vitamin K antagonists beat rivaroxaban and apixaban in the INVICTUS and PROACT Xa trials

J Thromb Haemost. 2023 Nov;21(11):3067-3071. doi: 10.1016/j.jtha.2023.06.036. Epub 2023 Jul 8.

Abstract

Although guidelines give preference to direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF), DOACs are not recommended in those with rheumatic heart disease or mechanical heart valves. The results of the INVICTUS trial (Investigation of Rheumatic AF Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies), which compared rivaroxaban with a VKA in patients with rheumatic heart disease-associated AF, and the PROACT Xa trial (A Trial to Determine if Participants with an On-X Aortic Valve Can be Maintained Safely on Apixaban), which compared apixaban with warfarin in patients with an On-X valve in the aortic position, support the use of VKAs for these indications. In this paper, we review the results of these trials, provide perspective on why VKAs were superior to DOACs, and discuss future directions for anticoagulation in these disorders.

Keywords: DOAC; INVICTUS; PROACT Xa; mechanical heart valve; rheumatic heart disease; warfarin.

Publication types

  • Review

MeSH terms

  • Administration, Oral
  • Anticoagulants / adverse effects
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / diagnosis
  • Atrial Fibrillation* / drug therapy
  • Dabigatran / therapeutic use
  • Fibrinolytic Agents / therapeutic use
  • Humans
  • Pyridones / therapeutic use
  • Rheumatic Heart Disease* / complications
  • Rheumatic Heart Disease* / drug therapy
  • Rivaroxaban / adverse effects
  • Stroke* / complications
  • Stroke* / drug therapy
  • Stroke* / prevention & control
  • Vitamin K
  • Warfarin / adverse effects

Substances

  • Warfarin
  • Rivaroxaban
  • apixaban
  • Anticoagulants
  • Pyridones
  • Vitamin K
  • Fibrinolytic Agents
  • Dabigatran