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The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
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Real-World Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial

Yu Yang1, Chin-Yao Shen2, Michael Chun-Yuan Cheng2

  • 1Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region (Y.Y., V.K.C.Y.).

Annals of Internal Medicine
|August 10, 2026
PubMed
Abstract

Insights

Direct oral anticoagulants (DOACs) may increase stroke risk but decrease heart attack risk in Asian patients with atrial fibrillation and mitral stenosis (AF-MS) compared to warfarin. Bleeding and death risks were similar.

Area of Science:

  • Cardiology
  • Pharmacology
  • Clinical Research

Background:

  • The safety and efficacy of direct oral anticoagulants (DOACs) versus warfarin in patients with atrial fibrillation and mitral stenosis (AF-MS) is debated.
  • This study addresses the controversy by comparing DOACs and warfarin in this specific patient population.

Purpose of the Study:

  • To evaluate the effectiveness and safety of DOACs compared to warfarin in patients diagnosed with atrial fibrillation and mitral stenosis (AF-MS).

Main Methods:

  • An observational cohort study utilized target trial emulation with population-wide insurance claims data from Taiwan.
  • Patients with AF-MS prescribed either DOACs or warfarin between 2011 and 2021 were analyzed.
  • Outcomes assessed included ischemic stroke, systemic embolism, myocardial infarction, bleeding events, and all-cause death at 1- and 5-year follow-ups.

Main Results:

  • DOACs were associated with a higher risk of ischemic stroke and composite stroke at 1-year follow-up compared to warfarin.
  • A decreased risk for myocardial infarction (MI) was observed with DOACs at 1 year.
  • Rivaroxaban specifically showed an increased ischemic stroke risk in both short- and long-term follow-ups. No significant differences in bleeding or all-cause death were found between the groups.

Conclusions:

  • In Asian patients with AF-MS, DOACs demonstrated an increased 1-year risk for stroke but a reduced risk for MI compared to warfarin.
  • The study highlights potential differential effects of anticoagulants in specific patient subgroups.

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