Direct oral anticoagulants slash serious events by 69% in intermediate-risk AF patients

In the open-label SINGLE-AF trial, 1,803 atrial fibrillation patients with intermediate stroke risk were randomized at 18 South Korean centers to receive a direct oral anticoagulant—either apixaban 5 mg twice daily or rivaroxaban 20 mg once daily—or no anticoagulation. After a median follow-up of 24 months, the primary composite outcome of stroke, systemic embolism, major bleeding, and cardiovascular death occurred in 0.5% of the anticoagulated group versus 1.5% of the control group, a 69% relative reduction (hazard ratio 0.31).

The reduction was largely due to a drop in ischemic strokes (0.1% vs 1.1%). Major bleeding rates were similar between groups (0.3% vs 0.5%). Presented at the ESC Congress 2026 and published in the New England Journal of Medicine, the trial provides the first randomized evidence supporting direct oral anticoagulants for patients at intermediate risk, potentially informing future guideline updates and reimbursement decisions.