The Impact of Direct Oral Anticoagulants vs. Warfarin on Stroke Prevention in Elderly Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis.

The outcomes of direct oral anticoagulants (DOACs) vs. warfarin have been well established in patients with atrial fibrillation (AF), but evidence regarding their safety and efficacy in preventing stroke or systemic embolism (SE) and reducing major bleeding in elderly patients remains inconclusive. This systematic review and meta-analysis aimed to compare the effectiveness of DOACs and warfarin in AF patients aged 75 years or older. The primary outcomes assessed were stroke prevention, bleeding risk, and all-cause mortality. A comprehensive literature search of databases including PubMed, Cochrane Library, and Google Scholar identified 10 relevant studies, which were included in the meta-analysis. The pooled hazard ratio for the composite outcome of stroke/SE or major bleeding was 0.84 (95% CI, 0.67-1.05; p = 0.12), indicating no statistically significant superiority of DOACs over warfarin in patients aged ≥75 years. The wide 95% CI, crossing unity, reflects imprecision and precludes definitive claims of either superiority or equivalence in this age group. Subgroup analyses suggested that the benefits of DOACs depend on patient age, comorbidities, and polypharmacy, with greater advantages observed in healthier subgroups. Significant heterogeneity was noted in relation to the type of DOAC and differences in follow-up duration. Assessment of publication bias using funnel plots and the Egger regression test indicated no significant bias, supporting the reliability of the findings. While this meta-analysis demonstrates generally favorable outcomes for DOACs, it also underscores the need for further studies to evaluate the long-term safety and feasibility of DOAC therapy in older AF patients, particularly those with complex comorbid conditions.