Comparative effectiveness and safety of direct oral anticoagulants in atrial fibrillation patients with dementia

Abstract

Introduction: Patients with atrial fibrillation (AF) and dementia face unique challenges in stroke prevention, particularly in selecting appropriate anticoagulation therapy. Direct oral anticoagulants (DOACs) effectively reduce stroke and embolism risks, but evidence comparing their effectiveness and safety in this population remains limited.

Methods: This retrospective, population-based cohort study used data from Taiwan's National Health Insurance Research Database to evaluate outcomes of four DOACs (dabigatran, apixaban, edoxaban, and rivaroxaban) in AF patients with dementia aged 50 years or older. We used propensity score matching to balance baseline characteristics across six DOAC comparison pairs.

Results: Dabigatran demonstrated superior outcomes, reducing the composite risk of ischemic stroke, acute myocardial infarction, intracranial hemorrhage, major bleeding, and all-cause mortality compared to apixaban (hazard ratio [HR], 0.82; 95 % confidence interval [CI], 0.73-0.92), edoxaban (HR, 0.81; 95 % CI, 0.71-0.92), and rivaroxaban (HR, 0.82; 95 % CI, 0.73-0.91). It also showed lower risks of intracranial hemorrhage and all-cause mortality. Sensitivity analyses excluding patients with nasogastric tubes or severe renal impairment showed smaller differences in overall outcomes but maintained dabigatran's advantage in reducing intracranial hemorrhage risk.

Conclusions: This study demonstrates the need for tailored anticoagulation strategies in this vulnerable population, with dabigatran emerging as a potentially safer and more effective option for stroke prevention in AF patients with dementia. Future research should examine individual DOAC effects across diverse clinical settings to optimize treatment outcomes.

Keywords: Anticoagulation; Atrial fibrillation; Dementia; Effectiveness; Safety.