Beneficial effects of DOACs in older patients with AF, even in those with HF


In a Japanese ANAFIE Registry, DOAC use was associated with lower risk of clinical outcomes in older non-valvular AF patients (≥75 years) compared with warfarin use, irrespective of the presence or absence of HF.

This summary is based on the publication of Ikeda S, Hiasa K, Inoue H, et al. - Clinical outcomes and anticoagulation therapy in elderly non-valvular atrial fibrillation and heart failure patients. ESC Heart Fail. 2024 Jan 11. doi: 10.1002/ehf2.14550.

Introduction and methods


AF and HF often coexist in patients, in particular among older adults, and this can affect the prognosis of patients with AF [1-5]. Old age and HF are both associated with impaired renal function, higher rates of persistent or permanent AF, and antiplatelet drug use [4, 6-8], which might impact clinical outcomes in patients with AF. It is unclear whether the real-world effectiveness of anticoagulation therapy is affected in older patients with AF and HF.

Aim of the study

This study aimed to (1) determine whether the presence of HF in older (≥75 years) non-valvular AF patients affects clinical outcomes, and (2) evaluate the effectiveness of DOACs versus warfarin on clinical outcomes in older non-valvular AF patients with or without HF.


The Japanse ANAFIE Registry was a multicenter, prospective, observational study that followed 33.062 older patients with non-valvular AF (aged ≥75 years) for 2 years. Exclusion criteria were: patients with CV events such as stroke and MI; cardiac intervention; hospitalization for HF; any bleeding leading to hospitalization 1 month prior; or life expectancy <1 year. The current analysis included data of 32.275 patients. Comparisons were made between patients with HF (n=12,116) and without HF (n=20,159) at baseline, and between patients who used DOAC (n=7780 in the HF group; n=13,805 in the non-HF group) or warfarin (n=3592 in the HF group; n=4641 in the non-HF group) at baseline.


Clinical outcomes were stroke/systemic embolism, major bleeding, HF hospitalization or cardiovascular mortality, cardiovascular events, cardiovascular mortality, all-cause mortality, and net clinical outcome.

Main results

  • Compared to the absence of HF, the presence of HF in older patients with AF was associated with higher risk for HF hospitalization or CV mortality (adjusted HR: 1.94; 95%CI: 1.78-2,12; P<0.001), CV events (adjusted HR: 1.59; 95%CI: 1.48-1.71; P<0.001), CV mortality (adjusted HR: 1.59; 95%CI: 1.48-1.71; P<0.001), all-cause mortality (adjusted HR: 1.32; 95%CI: 1.21-1.45; P<0.001), and net clinical outcome (adjusted HR: 1.23; 95%CI: 1.14-1.32; P<0.001), but not with stroke/systemic embolism (adjusted HR: 0.96; 95%CI: 0.83-1.10; P=0.56) or major bleeding (adjusted HR: 1.14; 95%CI: 0.96-1.35; P=0.13).
  • DOAC use was associated with lower risks of clinical events in older patients with AF compared with warfarin use irrespective of HF status. The adjusted HRs were:
    • 0.86 in HF vs. 0.79 in non-HF for stroke/systemic embolism; P for interaction=0.56;
    • 0.71 in HF vs. 0.75 in non-HF for major bleeding; P for interaction=0.74;
    • 0.81 in HF vs. 0.78 in non-HF for HF hospitalization or CV mortality; P for interaction=0.26;
    • 0.83 in HF vs. 0.82 in non-HF for CV events; P for interaction=0.65;
    • 0.84 in HF vs. 0.75 in non-HF for CV mortality; P for interaction=0.18;
    • 0.89 in HF vs. 0.80 in non-HF for all-cause mortality; P for interaction=0.91;
    • 0.88 in HF vs. 0.81 in non-HF for net clinical outcome; P for interaction=0.21.


In older patients aged ≥75 years with non-valvular AF of the ANAFIE Registry, the presence of HF was associated with higher risks of cardiovascular events and mortality compared with the absence of HF. DOAC use was associated with lower risk of clinical events in these patients compared with warfarin, regardless of the presence or absence of HF. The authors conclude that “[t]hese analyses might encourage the use of DOACs in elderly patients with non-valvular AF, even those with a history of HF”.

Find this article online at ESC Heart Fail.


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