Comparing Efficacy and Safety Between Patients with AF Taking DOACs or Warfarin After a DOAC Failure
CLINICAL QUESTION: Is warfarin better as a second-line anticoagulant than another direct oral anticoagulant (DOAC) in patients with atrial-fibrillation-induced ischemic strokes after failure of a first DOAC?
BACKGROUND: There is a relatively high (9.6%) risk of recurrent stroke in patients with atrial fibrillation (AF) despite compliance with DOAC use. Previous studies have shown that the risk ratios of ischemic safety endpoints are higher in patients switched to warfarin than in those without DOAC regimen changes after a DOAC failure. This study investigated the efficacy and safety of treatment with each of four different DOACs or warfarin after DOAC failure.
STUDY DESIGN: Retrospective cohort study
SETTING: National Health Research Database published by the Taiwan National Health Insurance Bureau between January 2003 and December 2016
SYNOPSIS: Retrospective analysis of the database identified 3,759 Asian patients with AF with ischemic stroke who experienced DOAC failure. The different outcomes of these patients with DOAC failure, including recurrent ischemic stroke (IS), major cardiovascular events (MACE), intracranial hemorrhage (ICH), subarachnoid hemorrhage (SAH), mortality, and net composite outcomes, were compared according to switching to the different DOACs or warfarin after index ischemic stroke. A total of 84 patients were identified who experienced a third IS after switching to different oral anticoagulants; 51 patients had ICH/SAH, 30 had recurrent fatal stroke, 164 had MACE, and 218 died. Four DOAC groups and one warfarin group were analyzed, and the data showed that compared against warfarin, switching to any of the four DOACs was associated with a 69% to 77% reduced risk of MACE and 69% to 83% reduced risk of net composite outcomes. Limitations include the inability to confirm that warfarin was in the therapeutic range for the analyzed patients, and that a relatively small number of patients were on edoxaban (7%), which could lead to unreliable statistics.
BOTTOM LINE: In Asian patients with DOAC failure, continuing DOACs after a second stroke was associated with fewer adverse outcomes than switching to warfarin.
CITATION: Hsieh MT, et al. Comparing efficacy and safety between patients with atrial fibrillation taking direct oral anticoagulants or warfarin after direct oral anticoagulant failure. J Am Heart Assoc. 2023;12(23):e029979. doi:10.1161/JAHA.123.029979.
Ms. Dreyer
Ms. Dreyer is a physician assistant in the department of hospital medicine at Duke Regional Hospital in Durham, N.C