Switching from Vitamin K Antagonists to Direct Oral Anticoagulants in Frail Elderly Patients with Atrial Fibrillation: Systematic Review and Meta-Analysis
In brief
Frail older adults with atrial fibrillation saw no benefit from switching blood thinners
Across four studies involving 57,099 frail older patients with atrial fibrillation, switching from vitamin K drugs to direct oral anticoagulants was not linked to fewer strokes, major bleeds or deaths than continuing the existing treatment. Results were also neutral in randomized trials, but the limited number of studies leaves uncertainty about which patients, if any, benefit from switching.
- Journal
- Medical sciences (Basel, Switzerland) (Q1)
- Published
- 25 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Paschalis Karakasis, Ricardo Gómez-Huelgas, Stylianos Tzeis, Konstantinos Vlachos, Konstantinos C Siontis, Alberto M Marra, et al.
- PMID
- 42783389
- DOI
- 10.3390/medsci14050516
Why clinicians should know about it
- Picked for Hematology (top studies of the week, 27 September 2026): Phase III RCT, practice-changing for adjuvant therapy
- Picked for Neurology (clinical) (top studies of the week, 27 September 2026): Anticoagulation switch meta‑analysis in frail elderly AF, cardiology
- Picked for Pharmacology (medical) (top studies of the week, 27 September 2026): DOAC switch vs VKA in frail elderly AF patients
Abstract
Background: Frailty complicates anticoagulation management in older patients with atrial fibrillation (AF), particularly when long-term vitamin K antagonist (VKA) therapy is already established. Whether switching to a direct oral anticoagulant (DOAC) improves outcomes in this setting remains uncertain, and guideline recommendations are limited. We performed a systematic review and meta-analysis comparing outcomes of VKA-to-DOAC switching versus VKA continuation in frail elderly patients with AF. Methods: MEDLINE, Scopus, and the Cochrane Library were systematically searched from inception through 4 April 2026. Studies enrolling frail elderly patients with AF receiving VKA therapy and directly comparing switching to a DOAC versus continued VKA treatment were eligible. The primary outcome was a composite of stroke/systemic embolism, major bleeding, or all-cause mortality. Adjusted hazard ratios (HRs) were pooled using three-level random-effects models. Results: Four studies (five treatment comparisons) comprising 57,099 patients were included. Overall, switching from VKA to DOAC therapy was not associated with a significant difference in the composite outcome compared with continued VKA treatment (HR 1.18, 95% CI 0.84-1.67). No significant differences were observed for major bleeding (HR 1.13, 95% CI 0.80-1.60), thromboembolism (HR 1.03, 95% CI 0.63-1.68), or all-cause mortality (HR 0.95, 95% CI 0.77-1.16). In analyses restricted to randomized trials, results remained neutral across all outcomes. Conclusion: In frail elderly patients with AF receiving VKA therapy, switching to a DOAC was not associated with significant reductions in thromboembolism, major bleeding, mortality, or the composite outcome compared with continued VKA treatment.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.