Long-term comparative efficacy and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation and chronic kidney disease: A nationwide observational study

doi:10.1016/j.hrthm.2026.06.020

Long-term comparative efficacy and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation and chronic kidney disease: A nationwide observational study

Heart RhythmPublished 23 Jun 2026Nationwide observational study

Main finding · Composite-safety (intracranial hemorrhage, gastrointestinal bleeding) and efficacy (ischemic stroke, myocardial infarction, embolism, all-cause mortality)ResultHazard ratio 0.57 95% CI 0.52–0.62

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Authors' conclusion

In patients with AF and CKD, OAC therapy improved efficacy outcomes without increasing bleeding risk. DOACs were more effective and safer than warfarin, supporting their use as the preferred anticoagulant in this high-risk population. Appropriate dosing and therapeutic monitoring are essential to maximize benefits and minimize bleeding complications.

Study context

Population: Patients with atrial fibrillation (AF) and chronic kidney disease (CKD)AF patients with CKD
Participants: 18,980 patients

Exposure: Oral anticoagulation (OAC) vs no OAC and direct oral anticoagulants (DOACs) vs warfarin
Outcome: Composite-safety (intracranial hemorrhage, gastrointestinal bleeding) and efficacy (ischemic stroke, myocardial infarction, embolism, all-cause mortality)

Methodological detailsClalit database

Clalit database

Main finding

As reported in the abstract

Composite-safety (intracranial hemorrhage, gastrointestinal bleeding) and efficacy (ischemic stroke, myocardial infarction, embolism, all-cause mortality)

Hazard ratio

0.57

95% CI 0.52–0.62

Primary composite efficacy outcome (ischemic stroke, myocardial infarction, embolism, all-cause mortality) — OAC vs no OAC

HR 0.57 (95% CI 0.52–0.62)

Observational data: associations, not effects.

Further findings

Outcome	← Lower risk ←→ Higher risk →	HR (95% CI)
All-cause mortality · reduced with OAC	0.20.5125	0.32 (0.29–0.36)
Composite bleeding and primary efficacy events among appropriately anticoagulated patients (subgroup) — DOACs vs warfarin · composite bleeding; no longer significant	0.20.5125	0.87 (0.52–1.47)
Composite bleeding and primary efficacy events among appropriately anticoagulated patients (subgroup) — DOACs vs warfarin · primary efficacy events; fewer with DOACs	0.20.5125	0.75 (0.60–0.94)
	0.20.5125Hazard ratio (log scale)

Thromboembolic events and bleeding outcomes (OAC vs no OAC)

No significant differences

Ischemic stroke (DOACs vs warfarin)

No significant differences

Safety

Outcome	← Lower risk with DOACs ←→ Higher risk with DOACs →	HR (95% CI)
Intracranial hemorrhage · higher rates with warfarin	0.20.5125	0.51 (0.32–0.8)
	0.20.5125Hazard ratio (log scale)

Parts of this Brief are withheld: the automatic checks could not confirm them against the abstract.

Original publication

Long-term comparative efficacy and safety of direct oral anticoagulants versus warfarin in patients with atrial fibrillation and chronic kidney disease: A nationwide observational study. Heart Rhythm. Published 23 June 2026. doi:10.1016/j.hrthm.2026.06.020

Read the original article ↗PubMed

Summarised from the published abstract; every number is checked against it