Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Vitamin K Antagonists in Elderly Patients With Atrial Fibrillation: A Systematic Review.

Anticoagulant therapy plays a pivotal role in preventing stroke and thromboembolic complications in elderly patients with atrial fibrillation, a population at increased risk for both ischemic and bleeding events. This systematic review evaluates the comparative efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in elderly patients with nonvalvular atrial fibrillation. A comprehensive literature search was conducted across PubMed, Embase, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL), following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and included only English-language randomized controlled trials (RCTs) focusing on patients aged 70 years or older. Five high-quality RCTs met the eligibility criteria. The findings consistently support the non-inferiority or superiority of DOACs compared to warfarin in preventing stroke, with a significantly lower risk of intracranial hemorrhage. However, a higher incidence of extracranial bleeding, particularly gastrointestinal bleeding, was observed with certain DOACs, especially at higher doses in patients aged 80 years and older. The review also highlights a possible role of anticoagulation in cognitive protection, although current evidence is limited. Overall, DOACs appear to be an effective and generally safer alternative to VKAs in elderly patients, but individualized treatment decisions remain essential, particularly in those with advanced age, renal impairment, or elevated bleeding risk.