Annals of Internal MedicineReal-World Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation and Mitral Stenosis: A Target Trial Emulation

ℹ️ Observational Association Only Evidence

A population-wide Taiwan claims analysis compared DOACs with warfarin in patients with atrial fibrillation and mitral stenosis. The study used target trial emulation to examine thrombotic, bleeding, cardiovascular, and mortality outcomes.

Clinical Considerations

• DOACs were associated with higher 1-year ischemic stroke risk versus warfarin in AF-MS.
• Composite stroke risk also increased, while MI risk decreased at 1-year follow-up.
• Rivaroxaban showed increased ischemic stroke risk during short- and long-term follow-up.
• Bleeding and all-cause mortality risks did not differ between treatment groups.

Practice Applications

• Interpret DOAC findings as observational and hypothesis-generating.
• Recognize AF-MS as distinct from broader nonvalvular AF populations.
• Consider guideline context before extrapolating DOAC use.
• Monitor future comparative evidence in mitral stenosis subgroups.