Systematic Review: Efficacy and Safety of Direct Oral Anticoagulants (Doacs) Versus Warfarin in Atrial Fibrillation (Af)

Author(s): Sara El Moussa, Ali Al Yasari, Aya Abdelfattah, Thuvan Dharvis Fathima Shasna, Ahmed Ibrahim haji Ahmed, Ala’a Thabet Abdel-Karim AL-Jarrad, Lakshmi Teja Pemmasani, Mohsin Abid, Saif Khalid

Background: The risk of thromboembolic event is greatly increased by atrial fibrillation (AF), the most common sustained arrhythmia in the world. The key to prevent stroke in AF is by anticoagulation. Direct oral anticoagulants (DOACs), which offer fixed dosage and fewer monitoring requirements, have become an alternative to warfarin, which has historically been the standard treatment.

Objective: Use real-world data, randomized controlled trials (RCTs), meta-analysis and guideline recommendations to systematically assess and compare the safety and effectiveness of DOACs versus warfarin in patients with non-valvular atrial fibrillation.

Methods: Studies published between 2008 and 2025 were systematically reviewed, including randomized controlled trials (RCTs), cohort studies, meta-analysis, guideline publications and observational registries. Outputs like major bleeding, intracranial hemorrhage (ICH), gastrointestinal bleeding, stroke prevention and treatment persistence were analyzed.

Results: Compared to warfarin, direct oral anticoagulants (DOACs) significantly decreased rates of intracranial hemorrhage (ICH) in the majority of populations and showed either same or superior efficacy in preventing stroke and systemic embolism. The best safety profile was consistently displayed by Apixaban. DOACs performed better than warfarin, especially for patients new to anticoagulants, high-risk elderly patients and those with inadequate international normalized ratio (INR) control. DOAC use was most beneficial for subgroups like Asians, the frail and patients with renal impairment.

Conclusion: DOACs are just as effective as warfarin and generally safer in preventing serious bleeding complications, especially intracranial hemorrhage. In terms of adherence, safety and efficacy, apixaban appears to be the best option. In certain subgroups, warfarin is still useful, but in general clinical settings, DOACs are becoming more effective.