Discrepant Outcomes of Direct Oral Anticoagulant Trials in Device-Detected Atrial Fibrillation after Stroke: Insights from NOAH-AFNET 6 and ARTESIA

The management of device-detected atrial fibrillation in patients with a history of stroke or transient ischemic attack remains a clinical dilemma, balancing the potential benefits of stroke prevention against the risks of anticoagulant-related bleeding. This review synthesizes evidence from the NOAH-AFNET 6 and ARTESIA trials, which evaluated the efficacy and safety of direct oral anticoagulants in this population. Collectively, randomized evidence regarding the use of direct oral anticoagulants in patients with device-detected atrial fibrillation and a history of stroke or transient ischemic attack remains limited and internally discordant. In ARTESIA, apixaban was associated with a reduction in ischemic stroke accompanied by an increase in major bleeding, yielding a relatively coherent benefit-risk signal in this high-risk subgroup. In contrast, NOAH-AFNET 6 demonstrated a modest and statistically non-significant reduction in ischemic stroke alongside a substantial increase in major bleeding. Further research is still needed to refine patient selection and optimize therapeutic strategies.