Stroke Prevention and Bleeding Risk in Patients with Non-Valvular Atrial Fibrillation Undergoing Surgery: A Comparative Analysis of NOACs versus Warfarin
Non-valvular atrial fibrillation (NVAF) is a common cardiac arrhythmia that increases the risk of thromboembolic events, especially during the perioperative period. Anticoagulation therapy with either novel oral anticoagulants (NOACs) or warfarin is essential for stroke prevention; however, managing these therapies around the time of surgery poses a clinical challenge due to the dual risks of bleeding and thrombosis. While NOACs have gained widespread use, their comparative safety and efficacy to warfarin in surgical settings remain inadequately defined. This study aimed to compare the effectiveness of NOACs versus warfarin in preventing perioperative stroke and minimizing bleeding complications among patients with NVAF undergoing surgery. A retrospective cohort study was conducted across three tertiary care hospitals in Pakistan, reviewing records from January 2020 to December 2024. A total of 300 patients with NVAF undergoing major elective or emergency surgeries were included, with 150 patients each in the NOAC and warfarin groups. Data on demographics, comorbidities, anticoagulant use, and perioperative outcomes (stroke/TIA, major bleeding, minor bleeding, transfusion needs, hospital stay, and 30-day outcomes) were analyzed using SPSS v26. Logistic regression was used to adjust for confounders. The incidence of stroke or TIA was low and similar in both groups (NOAC: 1.3% vs. warfarin: 3.3%; p = 0.24). However, major bleeding was significantly lower in the NOAC group (5.3%) compared to the warfarin group (12.7%; p = 0.02). Patients on NOACs also had fewer transfusion requirements (8% vs. 16.7%; p = 0.03) and shorter hospital stays (mean 4.6 vs. 6.1 days; p < 0.01). Logistic regression identified warfarin use (OR = 2.62), elevated HAS-BLED score, and renal impairment as significant predictors of major bleeding. NOACs demonstrated comparable stroke prevention but significantly lower bleeding risks and shorter hospital stays than warfarin in NVAF patients undergoing surgery. These findings support the preferential use of NOACs in the perioperative setting, especially when bleeding risk is a concern. Individualized risk assessment remains essential for optimal anticoagulation management.
