The Importance of Real-world Data: Outcomes of use of Direct-acting Oral Anticoagulants in Atrial Fibrillation

The Importance of Real-world Data: 

Outcomes of use of Direct-acting Oral Anticoagulants in Atrial Fibrillation

Yeela Talmor-Barkan, Nancy-Sarah Yacovzada, Hagai Rossman, Guy Witberg, Iris Kalka, Ran Kornowski, Eran Segal, Head-to-head efficacy and safety of rivaroxaban, apixaban, and dabigatran in an observational nationwide targeted trial, European Heart Journal - Cardiovascular Pharmacotherapy, Volume 9, Issue 1, January 2023, Pages 26–37, https://doi.org/10.1093/ehjcvp/pvac063

Key findings

• Treatment with rivaroxaban was associated with decreased rates of all-cause mortality, ischaemic stroke, and intracranial bleeding compared with apixaban.

• Rivaroxaban compared with dabigatran demonstrated decreased rate of all-cause mortality and ischaemic stroke in patients under the age of 70 years, and decreased rate of intracranial haemorrhage in patients aged 80 years or above.

• Rivaroxaban was associated with increased gastrointestinal bleeding compared with apixaban.

DT’s POV:

This study comes out of Israel. Notice how the rates of bleeding differs from previous reports when the spread of use of different DOACs differ. Rivaroxaban was associated with less intracranial bleeding but more gastrointestinal bleeding compared with Apixaban. Many previous meta-analyses and cohort or database studies suggest that Apixaban is associated with the least bleeding. Do you think it is a play of how commonly each DOAC is used, or is it related with patient / ethnic factors? 

Will we ever get a head-to-head randomised clinical trial comparing the 4 DOACs used in clinical practice today?