Apixaban Linked to Most Favorable Benefit-Risk Balance in Nursing Home Residents With AF and ADL Disability

Among long-term nursing home residents with atrial fibrillation (AF) and activities of daily living (ADL) disability, oral anticoagulant (OAC) use was associated with lower ischemic stroke rates but higher major bleeding rates than nonuse, according to a cohort study published in JAMA Network Open. Apixaban demonstrated the most favorable benefit-risk profile of the 3 OACs evaluated.

The retrospective study used US Medicare claims linked with the Minimum Data Set from 2013 to 2022 to emulate target trials in 26940 residents (median age, 82 years; 65.0% female) with nonvalvular AF and impairment in 3 or more ADLs. Propensity score–matched cohorts compared initiation of apixaban (n = 7600), rivaroxaban (n = 2654), or warfarin (n = 3216) with nonuse.

Compared with nonuse, all 3 OACs were associated with lower ischemic stroke rates (adjusted rate ratio [ARR], 0.53 for apixaban, 0.48 for rivaroxaban, and 0.47 for warfarin) and higher major bleeding rates (ARR, 1.62, 2.68, and 3.02, respectively). Only apixaban was not associated with a higher rate of the composite outcome (ARR, 1.08; 95% CI, 0.90-1.30), whereas rivaroxaban (ARR, 1.62; 95% CI, 1.20-2.18) and warfarin (ARR, 1.99; 95% CI, 1.50-2.63) were. In direct active-comparator analyses, apixaban was associated with similar ischemic stroke rates but lower major bleeding rates than rivaroxaban and warfarin.

In tipping-point analyses, anticoagulation became favorable when ischemic stroke was weighted 1.48 times more than major bleeding for apixaban, compared with 3.44 for rivaroxaban and 5.63 for warfarin. Stroke reduction with apixaban appeared attenuated among frail residents, although evidence of heterogeneity was limited. In 180-day intention-to-treat analyses, ischemic stroke reductions were no longer statistically significant.

The authors noted that residual confounding by indication could not be completely eliminated, that the claims-based frailty index may have caused misclassification, and that findings may not generalize beyond Medicare beneficiaries. They said the results may inform individualized anticoagulation decisions.

Source: Chen Q, Singer D, Yang CT, Pritchard KT, Kim DH, Lin KJ. Anticoagulation outcomes in nursing home residents with atrial fibrillation and ADL disability. JAMA Netw Open. 2026;9(10):e2637533. doi:10.1001/jamanetworkopen.2026.37533