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Published on: February 28, 2012
Comparative effectiveness of oral anticoagulants in everyday practice
A John Camm1, Keith A A Fox2, Saverio Virdone3
1Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George's University of London, London, UK jcamm@sgul.ac.uk.
Insights
Non-vitamin K antagonist oral anticoagulants (NOACs) reduce mortality and stroke risk in atrial fibrillation (AF) patients compared to warfarin. NOACs also show a lower risk of major bleeding, offering significant benefits in real-world practice.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- Real-world effectiveness of anticoagulants in atrial fibrillation (AF) is crucial for stroke prevention.
- Vitamin K antagonists (VKAs), direct thrombin inhibitors (DTIs), and factor Xa inhibitors (FXaIs) are used for stroke risk reduction in AF.
- Comparative data on these agents in routine clinical practice are essential.
Purpose of the Study:
- To compare the effectiveness and safety of VKAs, DTIs, and FXaIs in AF patients at risk of stroke.
- To evaluate outcomes including all-cause mortality, non-hemorrhagic stroke/systemic embolism, and major bleeding.
- To assess treatment effects in a large, real-world AF patient cohort.
Main Methods:
- Analysis of data from the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation registry.
- Inclusion of patients with AF and CHA 2 DS 2 -VASc score ≥ 2.
- Utilized propensity weighting, overlap weights, and Cox proportional hazards models for comparative analysis.
Main Results:
- Oral anticoagulant (OAC) therapy reduced mortality and stroke risk but increased major bleeding compared to no OAC.
- Non-vitamin K antagonist oral anticoagulant (NOAC) use was associated with lower mortality and stroke risk versus no OAC, with no increase in major bleeding.
- NOACs demonstrated lower mortality and major bleeding risk compared to VKAs, with similar stroke risk.
Conclusions:
- NOACs offer significant benefits over VKAs regarding mortality and major bleeding in AF patients.
- Real-world data support the effectiveness and safety of NOACs in stroke prevention for AF patients.
- No significant differences were observed among NOAC subtypes in this analysis.
Objectives:
This study evaluated the comparative effectiveness of vitamin K antagonists (VKAs), direct thrombin inhibitors (DTIs) and factor Xa inhibitors (FXaI) in patients with atrial fibrillation (AF) at risk of stroke in everyday practice.
Methods:
Data from patients with AF and Congestive heart failure, Hypertension, Age 75 years, Diabetes mellitus, prior Stroke, TIA, or thromboembolism, Vascular disease, Age 65-74 years, Sex category (CHA2DS2-VASc) score ≥2 (excluding gender) in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation registry were analysed using an improved method of propensity weighting, overlap weights and Cox proportional hazards models.
Results:
All-cause mortality, non-haemorrhagic stroke/systemic embolism (SE) and major bleeding over 2 years were compared in 25 551 patients, 7162 (28.0%) not treated with oral anticoagulant (OAC) and 18 389 (72.0%) treated with OAC (FXaI (41.8%), DTI (11.4%) and VKA (46.8%)). OAC treatment compared with no OAC treatment was associated with decreased risk of all-cause mortality (HR 0.82 (95% CI 0.74 to 0.91)) and non-haemorrhagic stroke/SE (HR 0.71 (95% CI 0.57 to 0.88)) but increased risk of major bleeding (HR 1.46 (95% CI 1.15 to 1.86)). Non-vitamin K antagonist oral anticoagulant (NOAC) use compared with no OAC treatment was associated with lower risks of all-cause mortality and non-haemorrhagic stroke/SE (HR 0.67 (95% CI 0.59 to 0.77)) and 0.65 (95% CI 0.50 to 0.86)) respectively, with no increase in major bleeding (HR 1.10 (95% CI 0.82 to 1.47)). NOAC use compared with VKA use was associated with lower risk of all-cause mortality and major bleeding (rates/100 patient-years 3.6 (95% CI 3.3 to 3.9) vs 4.8 (95% CI 4.5 to 5.2) and 1.0 (95% CI 0.9 to 1.1) vs 1.4 (95% CI 1.2 to 1.6); HR 0.79 (95% CI 0.70 to 0.89) and 0.77 (95% CI 0.61 to 0.98) respectively), with similar risk of non-haemorrhagic stroke/SE (rates/100 patient-years 0.8 (95% CI 0.7 to 0.9) versus 1.0 (95% CI 0.8 to 1.1); HR 0.96 (95% CI 0.73 to 1.25).
Conclusion:
Important benefits in terms of mortality and major bleeding were observed with NOAC versus VKA with no difference among NOAC subtypes.
Trial Registration Number:
NCT01090362.
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