Clinical Outcomes of Non Vitamin K Antagonist Oral Anticoagulants versus Vitamin K Antagonist Oral Anticoagulants in Non Valvular Atrial Fibrillation Patients: A Cohort Study in a Rural Tertiary Care Hospital, Gujarat, India

Introduction: Atrial Fibrillation (AF) is the most common arrhythmia, with an increased risk of ischaemic stroke and subsequent morbidity and mortality. Oral anticoagulants such as Vitamin K Antagonists (VKAs) and non VKA Oral Anticoagulants (NOACs) are effective stroke prevention treatments, when used properly. The CHA2 DS2 -VASc and HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly (age >65 years), and Drugs/ alcohol) scores are utilised to guide clinical decision-making in stroke prevention and bleeding risk management for patients with AF. However, real-world evidence on anticoagulation strategies and their effectiveness in rural Indian populations remains limited. Aim: To evaluate the clinical outcomes of NOACs versus VKAs in Non Valvular Atrial Fibrillation (NVAF) patients in a rural tertiary care hospital in India. Materials and Methods: An ambidirectional cohort study, conducted from January 2014 to December 2024, evaluated baseline demographic and clinical characteristics and anticoagulation therapy (NOACs or VKAs) in NVAF patients. Clinical outcomes evaluated encompass major (example: ischaemic or haemorrhagic stroke) and minor bleeding, and allcause mortality. Fisher’s exact test was used to compare patient and clinical characteristics between the NOAC and VKA groups. The log-rank test and Cox proportional hazards analysis were used to compare bleeding risk and mortality between NOAC and VKA groups. Results: Among the 347 patients with NVAF, those prescribed NOACs were significantly older (median age 74 vs. 58 years, p-value <0.0001) and had higher CHA2DS2-VASc scores (median 4 vs. 3, p-value <0.0001) than VKA users. NOAC users also had a higher prevalence of hypertension, diabetes, ischaemic heart disease, prior stroke and chronic kidney disease (p-value <0.0001). Major bleeding was slightly more common in NOAC patients (2.9 vs. 2.1 events per 1,000 person-months, p-value=0.40). The log-rank test showed no significant difference in major bleeding event between NOAC and VKA groups (p-value=0.10). However, all-cause mortality was higher in NOAC users (11.6 vs. 7.7 per 1,000 personmonths). Conclusion: Although NOACs are generally favoured in AF management, this study found higher mortality and bleeding risks among NOAC users in a rural Indian cohort. Older age, higher burden of co-morbidities, being underweight and higher stroke and thromboembolic risk can contribute to adverse outcomes among NOAC users. These findings highlight the need for individualised anticoagulation strategies, particularly in resource-limited settings.