# Direct oral anticoagulants vs warfarin in non-valvular atrial fibrillation — which is preferred?

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**Summary:** DOACs are at least as effective as warfarin with less intracranial bleeding, and are preferred first-line in non-valvular AF.

In non-valvular atrial fibrillation, direct oral anticoagulants (DOACs) are at least as effective as warfarin for preventing stroke and systemic embolism, with a better safety profile. A meta-analysis of the four pivotal phase 3 trials (>71,000 patients) found DOACs reduced stroke or systemic embolism by 19% versus warfarin, driven largely by fewer haemorrhagic strokes [1].

DOACs also reduced all-cause mortality and, notably, intracranial haemorrhage by roughly half compared with warfarin [1]. Gastrointestinal bleeding was higher with some DOACs at some doses.

These findings, together with the practical advantages of fixed dosing and no routine monitoring, make DOACs the preferred first-line anticoagulant in most patients with non-valvular AF. They are not appropriate in mechanical heart valves or moderate-to-severe mitral stenosis [1].

## Limitations

- Data do not apply to mechanical valves or rheumatic mitral stenosis, where warfarin remains standard.
- Dose selection matters (renal function, age, weight); GI bleeding risk is increased with some agents/doses.

## Sources

1. [III / Systematic review] Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. The Lancet (2014). DOI 10.1016/S0140-6736(13)62343-0. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)62343-0/abstract

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