DIRECT ORAL ANTICOAGULANTS VERSUS WARFARIN AFTER ISCHEMIC STROKE IN PATIETS WITH ATRIAL FIBRILLATION: A POPULATION-BASED STUDY FROM BRAZIL
Author(s)
Henrique Diegoli, MSc, MD1, Pedro Magalhaes, MD2, Alexandre Luis Longo, MD2, Ivonei Bittencourt, MSc3, Rafaela Bitencourt Liberato, MSc3, Vivian Nagel, PhD3, Vanessa Guesser Venâncio, BSN3, Ana B. Zen, BSc1, João V. Grazziotin, BSc(c)1, Letícia Wernke dos Santos, BSN1, Carla Heloísa Cabral Moro, MD4;
1HEOR Valor, Joinville, Brazil, 2Neurologica, Joinville, Brazil, 3Joinville Stroke Registry, Joinville, Brazil, 4Hospital Municipal São José, Joinville, Brazil
1HEOR Valor, Joinville, Brazil, 2Neurologica, Joinville, Brazil, 3Joinville Stroke Registry, Joinville, Brazil, 4Hospital Municipal São José, Joinville, Brazil
OBJECTIVES: Clinical trials have shown that direct oral anticoagulants (DOACs) are comparable or superior to warfarin in efficacy and safety for stroke prevention in patients with atrial fibrillation (AF). However, warfarin has important limitations, including the need for frequent monitoring, drug-drug and dietary interactions, which may compromise its effectiveness in real-world settings. We investigated the effectiveness of DOACs versus warfarin for secondary prevention of ischemic stroke in patients with atrial fibrillation in a real-world Brazilian population.
METHODS: We used data from the Joinville Stroke Registry (Joinvasc), including patients with ischemic stroke and non-valvular AF who were discharged on DOACs or warfarin between 2018 and 2024. Patients were followed until April 2025 or for up to 5 years after the index event. The primary outcome, stroke-free survival (SFS), was compared using Cox proportional hazards regression, with proportionality assessed using the Schoenfeld test. Propensity score matching (PSM) was subsequently performed, adjusting for CHA₂DS₂-VASc score and social class.
RESULTS: Among 7,289 patients admitted with stroke, 604 had non-valvular AF and were discharged with an oral anticoagulant. SFS events occurred in 130/322 (40.4%) patients treated with warfarin and in 73/282 (25.9%) patients treated with DOACs, yielding a hazard ratio (HR) of 0.71 (95% confidence interval [95% CI] 0.51-0.98). After PSM, the HR was 0.64 (95% CI 0.45-0.91). Both analyses indicated one fewer stroke or death per 10 treated patients in the DOAC group over a 2-year follow-up. The proportional hazards assumption was met before (p = 0.34) and after (p = 0.38) PSM.
CONCLUSIONS: These real-world findings have important implications for Brazil, supporting broader DOAC use in clinical practice and informing public health policies aimed at reducing recurrent stroke, healthcare burden, and long-term disability associated with atrial fibrillation.
METHODS: We used data from the Joinville Stroke Registry (Joinvasc), including patients with ischemic stroke and non-valvular AF who were discharged on DOACs or warfarin between 2018 and 2024. Patients were followed until April 2025 or for up to 5 years after the index event. The primary outcome, stroke-free survival (SFS), was compared using Cox proportional hazards regression, with proportionality assessed using the Schoenfeld test. Propensity score matching (PSM) was subsequently performed, adjusting for CHA₂DS₂-VASc score and social class.
RESULTS: Among 7,289 patients admitted with stroke, 604 had non-valvular AF and were discharged with an oral anticoagulant. SFS events occurred in 130/322 (40.4%) patients treated with warfarin and in 73/282 (25.9%) patients treated with DOACs, yielding a hazard ratio (HR) of 0.71 (95% confidence interval [95% CI] 0.51-0.98). After PSM, the HR was 0.64 (95% CI 0.45-0.91). Both analyses indicated one fewer stroke or death per 10 treated patients in the DOAC group over a 2-year follow-up. The proportional hazards assumption was met before (p = 0.34) and after (p = 0.38) PSM.
CONCLUSIONS: These real-world findings have important implications for Brazil, supporting broader DOAC use in clinical practice and informing public health policies aimed at reducing recurrent stroke, healthcare burden, and long-term disability associated with atrial fibrillation.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
CO5
Topic
Clinical Outcomes
Topic Subcategory
Clinical Outcomes Assessment, Comparative Effectiveness or Efficacy
Disease
No Additional Disease & Conditions/Specialized Treatment Areas, SDC: Cardiovascular Disorders (including MI, Stroke, Circulatory)