Non-vitamin K antagonist Oral Anticoagulants (NOACs) have become the mainstay therapy for stroke prophylaxis in atrial fibrillation. Although shown equally or more safe and effective than warfarin, there is limited knowledge of the comparative effectiveness and safety of the NOACs.

Afib.no network members have addressed this in a recent publication in the European Heart Journal – Cardiovascular Pharmacotherapy, making direct comparisons between the NOACs dabigatran, rivaroxaban and apixaban, investigating risk of stroke or systemic embolism, as well as major bleeding, in a large registry-based cohort of patients with atrial fibrillation.

Using data from the Norwegian Prescription Registry (NPR) and the Norwegian Prescription Database (NorPD), they identified 52 476 anticoagulant-naïve patients initiating therapy with a NOAC between January 2013and December 2017.

Using propensity score estimation and matching, balanced cohorts of patients using dabigatran, rivaroxaban and apixaban were created, and direct comparisons made.

Their findings show that among users of NOACs, while no statistically significant differences were seen in effectiveness (stroke prevention), there were significant differences in the associated bleeding risk; dabigatran and apixaban being associated with significantly lower risks of major bleeding compared with rivaroxaban.

“There are no randomized controlled trials to shed light on the very important challenge that every clinician in our field is faced with every day: which NOAC should I choose for my patient? That is why observational data are so important – they are the only source of information that we have” – first author Ole-Christian Rutherford says.

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