ArticleInternal and emergency medicine2026
Outcomes of non-valvular atrial fibrillation elderly patients maintained on VKAs' treatment compared to patients switched to DOACs: results from the START
Article in Internal and emergency medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Direct oral anticoagulants (DOAC) have similar efficacy for stroke prevention in patients with non-valvular atrial fibrillation (AF) with improved safety. Recently, a higher bleeding risk was reported when elderly AF patients were switched from VKAs to DOACs. AF patients aged ≥ 75 years who were maintained on VKA treatment or who were switched from VKAs to DOACs at the time of enrollment in the START-AF Register were followed. Bleedings, thrombotic events, and deaths that occurred during follow-up were collected. We included 4230 AF patients, 2930 (69.3%) on VKAs and 1300 patients (30.7%) shifted to DOACs. Low-dose DOACs were prescribed to 732 (56.3%) patients, 257 (35.1%) of whom received off-label low-dose. Thrombotic events were more frequent among patients switched to DOACs compared to patients continuing VKAs (1.0 and 0.6 × 100pt-yrs p = 0.05). The rate of bleeding events was similar between the two groups (3.0 and 2.5 × 100pt-yrs; p = 0.2), and was higher in the subgroup treated with on-label low-dose DOACs (3.4 × 100pt/yrs) compared to patients on VKAs (2.5 × 100pt-yrs)(RR1.4, 95%CI 0.9-2.0; p = 0.1). Conversely, patients on off-label low-dose DOACs showed higher rates of thrombotic events compared to patients on VKAs (1.4 vs 0.6 × 100pt/yrs, p = 0.05). Mortality was significantly higher in VKA patients than in DOACs patients independently from the dosage (6.7 and 2.9 × 100pt-years; p = 0.05). Elderly AF patients switched from VKAs to DOACs are at increased risk of thrombotic events than patients who remain on VKAs but with a lower risk of mortality. Switching to low-dose DOACs may expose patients to a higher risk of adverse outcomes.
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