Durham, NC—While current clinical guidelines recommend direct oral anticoagulants (DOACs) over warfarin for stroke prevention in patients with atrial fibrillation (AF) who are at high risk, the benefits are not completely clear, according to a new study.

The study published in JAMA Neurology sought to determine if DOAC therapy is a better option than warfarin for secondary prevention in older survivors of ischemic stroke who have AF.

Duke University Medical Center–led researchers point out that, despite demonstrated efficacy in clinical trials, real-world data of DOACs versus warfarin are primarily based on administrative claims or have not really focused on patient-centered outcomes.

“From a patient’s perspective, an important measure of the benefit of anticoagulant treatment beyond survival is the prevention of recurrent events or prolonged hospital stays,” the study explained. “Survivors of stroke have identified ‘being alive at home, without recurrent stroke, or being hospitalized for complications’ as the most desirable outcome. Such patient-centered outcomes have not been well studied as an end point in research on DOACs.”

The study team set out to examine the clinical effectiveness of dabigatran, rivaroxaban, or apixaban compared with warfarin after ischemic stroke in AF patients.

Participants were aged 65 years or older, had AF, were anticoagulation-naive, and were discharged from 1,041 Get With The Guidelines–Stroke–associated hospitals for acute ischemic stroke between October 2011 and December 2014. Researchers linked the data to Medicare claims for long-term outcomes until December 2015, with analyses completed in July 2018.

Defined as the primary outcomes were home time, a patient-centered measure defined as the total number of days free from death and institutional care after discharge, and major adverse cardiovascular events.

The articles notes that, of 11,662 survivors of acute ischemic stroke with a median age of 80 years, 34.7% were discharged with DOACs and the remainder with warfarin. The study team explains that, except for National Institutes of Health Stroke Scale scores (median [interquartile range], 4 [1-9] vs. 5 [2-11]), baseline characteristics were similar between groups.

Results indicate that patients discharged with DOACs had more days at home (mean [SD], 287.2 [114.7] vs. 263.0 [127.3] days; adjusted difference, 15.6 [99% CI, 9.0-22.1] days) during the first year postdischarge and were less likely to experience major adverse cardiovascular events (adjusted hazard ratio [aHR], 0.89 [99% CI, 0.83-0.96]) compared with those receiving warfarin.

Furthermore, fewer deaths occurred in patients receiving DOACs (aHR, 0.88 [95% CI, 0.82-0.95]; P <.001); all-cause readmissions (aHR, 0.93 [95% CI, 0.88-0.97]; P = .003); cardiovascular readmissions (aHR, 0.92 [95% CI, 0.86-0.99]; =.02), hemorrhagic strokes (aHR, 0.69 [95% CI, 0.50-0.95]; P = .02); and hospitalizations with bleeding (aHR, 0.89 [95% CI, 0.81-0.97]; P = .009). Those patients had a higher risk of gastrointestinal bleeding (aHR, 1.14 [95% CI, 1.01-1.30]; P = .03) than the patients treated with warfarin, however, according to researchers.

“In patients with acute ischemic stroke and AF, DOAC use at discharge was associated with better long-term outcomes relative to warfarin,” study authors conclude.

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