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Peer-reviewedCC BY-NC-NDInternational Journal of Cardiology. Cardiovascular Risk and Prevention

Real-world comparative effectiveness and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation

  • Sureerat Suwatcharangkoon1
  • Sasivimol Rattanasiri2
  • Nattawut Unwanatham3
  • Pawin Numthavaj3
  • Thosaphol Limpijankit4
  • Gareth J. McKay5
  • John Attia6
  • Ammarin Thakkinstian3
6 affiliations
  1. 1Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Bangkok, Khet Ratchathewi, 10400, Thailand; Division of Neurology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Bangkok, Khet Ratchathewi, 10400, Thailand
  2. 2Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Bangkok, Khet Ratchathewi, 10400, Thailand; Corresponding author.
  3. 3Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Bangkok, Khet Ratchathewi, 10400, Thailand
  4. 4Division of Cardiology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Thung Phaya Thai, Bangkok, Khet Ratchathewi, 10400, Thailand
  5. 5Centre for Public Health, Queen's University Belfast, 97 Lisburn Road, Whitla Medical Building, Belfast, Northern Ireland, BT9 7BL, United Kingdom
  6. 6School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, 2308, Australia
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Abstract

Background and purpose: Long-term oral anticoagulants (OACs), either vitamin K antagonists or direct oral anticoagulants (DOACs), are essential for stroke prevention in atrial fibrillation (AF). However, comparative real-world evidence among DOACs in upper-middle-income settings remains inconsistent. This study compared the effectiveness and safety of DOACs with warfarin in reducing stroke or systemic embolism (SSE), major bleeding, and all-cause mortality in patients with AF. Methods: We conducted a retrospective cohort study of patients with non-valvular AF newly prescribed OACs between 2010 and 2021 using the Ramathibodi Hospital database. Inverse probability weighting (IPW) was applied to balance baseline covariates and emulate a RCT. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using IPW-adjusted Cox proportional hazards models. Results: Among 5580 patients, 4237 received warfarin, 414 dabigatran, 428 rivaroxaban, 413 apixaban, and 88 edoxaban. Compared with warfarin, apixaban (HR 0.35; 95% CI 0.18, 0.67) was associated with significantly lower risks of SSE. Dabigatran (HR 0.43; 95% CI 0.23, 0.81) and rivaroxaban (HR 0.47; 95% CI 0.25, 0.90) significantly reduced the major bleeding risk. No DOAC was associated with reduced all-cause mortality. Sensitivity analyses confirmed the robustness of the findings. Conclusion: Apixaban showed the most favorable profile with significant reductions in SSE and trend toward lower major bleeding compared with warfarin, supporting its preferential use for stroke prevention in this setting.

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Cite

BibTeXRIS
BibTeX
@article{suwatcharangkoon2026realworld,
  title = {{Real-world comparative effectiveness and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation}},
  author = {Sureerat Suwatcharangkoon and Sasivimol Rattanasiri and Nattawut Unwanatham and Pawin Numthavaj and Thosaphol Limpijankit and Gareth J. McKay and John Attia and Ammarin Thakkinstian},
  journal = {International Journal of Cardiology. Cardiovascular Risk and Prevention},
  year = {2026},
  month = oct,
  doi = {10.1016/j.ijcrp.2026.200719},
  url = {https://doi.org/10.1016/j.ijcrp.2026.200719},
  note = {CC BY-NC-ND},
}
RIS
TY  - JOUR
TI  - Real-world comparative effectiveness and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation
AU  - Sureerat Suwatcharangkoon
AU  - Sasivimol Rattanasiri
AU  - Nattawut Unwanatham
AU  - Pawin Numthavaj
AU  - Thosaphol Limpijankit
AU  - Gareth J. McKay
AU  - John Attia
AU  - Ammarin Thakkinstian
PY  - 2026
DA  - 2026/10/17
JO  - International Journal of Cardiology. Cardiovascular Risk and Prevention
DO  - 10.1016/j.ijcrp.2026.200719
UR  - https://doi.org/10.1016/j.ijcrp.2026.200719
AB  - Background and purpose: Long-term oral anticoagulants (OACs), either vitamin K antagonists or direct oral anticoagulants (DOACs), are essential for stroke prevention in atrial fibrillation (AF). However, comparative real-world evidence among DOACs in upper-middle-income settings remains inconsistent. This study compared the effectiveness and safety of DOACs with warfarin in reducing stroke or systemic embolism (SSE), major bleeding, and all-cause mortality in patients with AF. Methods: We conducted a retrospective cohort study of patients with non-valvular AF newly prescribed OACs between 2010 and 2021 using the Ramathibodi Hospital database. Inverse probability weighting (IPW) was applied to balance baseline covariates and emulate a RCT. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using IPW-adjusted Cox proportional hazards models. Results: Among 5580 patients, 4237 received warfarin, 414 dabigatran, 428 rivaroxaban, 413 apixaban, and 88 edoxaban. Compared with warfarin, apixaban (HR 0.35; 95% CI 0.18, 0.67) was associated with significantly lower risks of SSE. Dabigatran (HR 0.43; 95% CI 0.23, 0.81) and rivaroxaban (HR 0.47; 95% CI 0.25, 0.90) significantly reduced the major bleeding risk. No DOAC was associated with reduced all-cause mortality. Sensitivity analyses confirmed the robustness of the findings. Conclusion: Apixaban showed the most favorable profile with significant reductions in SSE and trend toward lower major bleeding compared with warfarin, supporting its preferential use for stroke prevention in this setting.
SN  - 2772-4875
ER  -