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The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
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DOACs vs warfarin in AF with comorbid CKD or valvular disease: a systematic review and meta-analysis

Aileen Liang1, Cathy Wang1, Alla E Iansavitchene2

  • 1Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.

Blood Vessels, Thrombosis & Hemostasis
|December 24, 2025
PubMed

Insights

Direct oral anticoagulants (DOACs) show reduced bleeding and stroke risk compared to warfarin in patients with atrial fibrillation (AF) and chronic kidney disease (CKD) or valvular disease. These findings suggest DOACs may be superior for preventing thromboembolic events and reducing bleeding in these specific patient groups.

Area of Science:

  • Cardiology
  • Nephrology
  • Pharmacology

Background:

  • Direct oral anticoagulants (DOACs) are typically not indicated for patients with atrial fibrillation (AF) who have valvular disease or severe chronic kidney disease (CKD).
  • Warfarin has been the preferred anticoagulant for these patient populations.
  • The safety and efficacy of DOACs in these specific groups require thorough evaluation.

Purpose of the Study:

  • To evaluate the safety and efficacy of DOACs compared to warfarin in patients with AF.
  • Specifically assess outcomes in patients with concomitant valvular disease or CKD.
  • Determine if DOACs offer benefits in terms of bleeding and thromboembolic events in these populations.

Main Methods:

  • Conducted a systematic review of randomized-controlled trials (RCTs) and non-RCTs.
  • Searched databases including MEDLINE, Embase, and Evidence Based Medicine Reviews.
  • Included studies reporting on bleeding, stroke, or thromboembolism in patients with AF and CKD or valvular disease, comparing DOACs (rivaroxaban, dabigatran, apixaban, edoxaban) with warfarin.
  • Performed meta-analysis using a random effects model.

Main Results:

  • Included 110 studies with over 400,000 patients.
  • In patients with AF and CKD, DOACs significantly reduced bleeding (OR, 0.66; 95% CI, 0.49-0.88) and strokes (OR, 0.60; 95% CI, 0.43-0.85) compared to warfarin, especially in advanced CKD stages and dialysis patients.
  • In patients with AF and valvular disease, DOACs also showed reduced bleeding (OR, 0.75; 95% CI, 0.57-0.97) and stroke incidence (OR, 0.66; 95% CI, 0.47-0.93) compared to warfarin.

Conclusions:

  • DOACs demonstrate a favorable safety and efficacy profile in patients with AF and concomitant CKD or valvular disease.
  • DOACs may be equivalent or superior to warfarin in preventing thromboembolic events and reducing bleeding in these patient groups.
  • Findings support considering DOACs for patients with AF who have these specific comorbidities.

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