J Am Heart Assoc

What to do in afib patients after DOAC failure

December 11, 2023

Among Asian patients with direct oral anticoagulant (DOAC) failure, continuing DOACs after index stroke was associated with fewer undesirable outcomes compared with switching to a vitamin K antagonist (VKA).

• This retrospective analysis included patients with atrial fibrillation with ischemic stroke despite DOAC treatment between January 2002 and December 2016. Outcomes of patients with DOAC failure were compared, including recurrent ischemic stroke, major CV events, intracranial hemorrhage and subarachnoid hemorrhage, mortality, and net composite outcomes according to switching to different DOACs or vitamin K antagonist after index ischemic stroke.
• Investigators identified 3,759 patients with DOAC failure. A total of 84 patients experienced recurrent ischemic stroke after switching to different oral anticoagulants, during a total follow-up period of 14 years. Using the vitamin K antagonist group as a reference, switching to any of the 4 DOACs was associated with a 69% to 77% reduced risk of major CV events (adjusted hazard ratio [aHR], 0.25 [95% confidence interval (CI), 0.16-0.39] for apixaban, 0.23 [95% CI, 0.14-0.37] for dabigatran, 0.23 [95% CI, 0.09-0.60] for edoxaban, and 0.31 [95% CI, 0.21-0.45] for rivaroxaban). In addition, there was a 69% to 83% reduced risk of net composite outcomes (aHR, 0.25 [95% CI, 0.18-0.35] for apixaban, 0.17 [95% CI, 0.11-0.25] for dabigatran, 0.31 [95% CI, 0.17-0.56] for edoxaban, and 0.31 [95% CI, 0.23-0.41] for rivaroxaban).
• Authors conclude that future studies may be warranted to compare whether a particular DOAC has a better net clinical benefit. They also highlight the need to test novel nonpharmacologic or pharmacologic treatment options for this high‐risk population.

Source:

Hsieh M-T, et al. (2023, December 3). J Am Heart Assoc. Comparing Efficacy and Safety Between Patients With Atrial Fibrillation Taking Direct Oral Anticoagulants or Warfarin After Direct Oral Anticoagulant Failure. https://pubmed.ncbi.nlm.nih.gov/38038171/