Real-World Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation and Mitral Stenosis : A Target Trial Emulation.

Authors

Yu Yang, Chin-Yao Shen, Michael Chun-Yuan Cheng, Wei Kang, Philip C M Au, Vincent K C Yan, Huei-Kai Huang, Chun Ka Wong, Kai Hang Yiu, Hung-Fat Tse, Ching-Lung Cheung, Timothy H Rainer, Bryan P Yan, David C W Siu, Ian Chi Kei Wong, Edward Chia-Cheng Lai, Esther W Y Chan

Published in

Annals of internal medicine. Aug 11, 2026. Epub Aug 11, 2026.

Abstract

Whether direct oral anticoagulants (DOACs) are a safe and effective alternative to warfarin in patients with atrial fibrillation and mitral stenosis (AF-MS) remains controversial.
To evaluate the effectiveness and safety of DOACs versus warfarin in patients with AF-MS.
Observational cohort study using target trial emulation.
Population-wide insurance claims data in Taiwan.
Patients diagnosed with AF-MS and prescribed either DOACs or warfarin between 1 January 2011 and 31 December 2021 were included in the study.
DOACs or warfarin.
Absolute risk differences (RDs) and risk ratios (RRs) at 1 year and 5 years of follow-up for ischemic stroke, systemic embolism, composite stroke, myocardial infarction (MI), intracranial hemorrhage, gastrointestinal bleeding, bleeding at other critical sites, and all-cause death.
Compared with warfarin, DOACs were associated with an increased risk for ischemic stroke (RD, 4.97 percentage points [95% CI, 1.27 to 8.57 percentage points]; RR, 1.22 [CI, 1.05 to 1.41]) and composite stroke (RD, 5.56 percentage points [CI, 1.77 to 8.97 percentage points]; RR, 1.23 [CI, 1.07 to 1.42]) and a decreased risk for MI (RD, -1.61 percentage points [CI, -3.17 to -0.03 percentage points]; RR, 0.61 [CI, 0.37 to 0.99]) at the 1-year follow-up. Rivaroxaban increased the risk for ischemic stroke during both short- and long-term follow-up periods. The 2 groups did not differ in risks for bleeding or all-cause death.
Limited sample size, lack of detailed information on MS severity, and lack of international normalized ratio measurements.
In Asian patients with AF-MS, DOACs were associated with an increased 1-year risk for stroke but a decreased risk for MI compared with warfarin.
Research Grants Council of Hong Kong.

PMID:
42574730
Bibliographic data and abstract were imported from PubMed on 11 Aug 2026.

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