Switching to DOACs may prevent stroke, bleeding, death in older patients

Older patients on a vitamin K antagonist (VKA) derive benefits from switching to standard-dose (SD) direct-acting oral anticoagulant (DOAC) as shown by significant decreases in stroke or systemic embolism, fatal and intracranial bleeding, and death, reveals a study. 

Overall, 5,913 patients who were frail, older (age ≥75 years), and VKA-experienced and 52,721 patients who did not meet all of this criteria were included in the analysis. Participants were then randomly assigned to receive either SD-DOAC or warfarin. 

After a median follow-up of 27 months, no heterogeneity in treatment effect with SD-DOAC vs warfarin was observed among patients who met all three criteria, compared with those who did not, for stroke or systemic embolic events (hazard ratio [HR]: 0.83 vs 0.81; p=0.75) or death (HR: 0.95 vs 0.91; p=0.54). 

Major bleeding did not differ between SD-DOAC and warfarin groups in frail, older, VKA-experienced patients (HR, 1.06, 95 percent confidence interval [CI], 0.90–1.25), but it was significantly lower with SD-DOAC in patients who did not meet all three criteria (HR, 0.82, 95 percent CI, 0.76–0.89; p=0.007). 

The net clinical outcome was also similar in the frail, older, VKA-experienced patients treated with SD-DOAC vs warfarin (HR, 1.01, 95 percent CI, 0.91–1.13), but there was a significant reduction with SD-DOAC patients without all three criteria (HR, 0.89, 95 percent CI, 0.85–0.93; p=0.028). 

Fatal and intracrial bleeding significantly decreased with SD-DOAC in both subgroups to a similar degree (p>0.05 for both), whereas gastrointestinal bleeding with SD-DOAC was higher in frail, older, VKA-experiened patients (HR, 1.83, 95 percent CI, 1.42–2.36) than in those without all three criteria (HR, 1.23, 95 percent CI, 1.09–1.39; p=0.006). 

“Based on these findings, SD-DOAC is a reasonable choice for frail, older, VKA-experienced patients to reduce stroke and systemic embolism, death, and the most serious types of bleeding,” the authors said.