AIMS: Patients with device-detected atrial fibrillation (DDAF) have a lower stroke risk than those with ECG-diagnosed AF, requiring careful evaluation of oral anticoagulation benefits vs. its inherent bleeding risk. METHODS AND RESULTS: An unmatched win ratio analysis was performed of the NOAH-AFNET 6 trial dataset, using components of the primary efficacy and safety outcomes of the trial. The primary analysis used this hierarchical order: (1) all-cause death, (2) stroke, (3) systemic or pulmonary embolism/myocardial infarction, and (4) major bleeding. Two additional analyses replaced all-cause death with cardiovascular death or included patient-reported outcomes. Win odds were calculated to account for undecided comparisons. Among 2534 patients 77 ± 7 years old, 947 (37%) women, median CHA2DS2-VA score 3 [interquartile range (IQR), 3-4], median follow-up 21 months (IQR, 10-38) 1 605 280 win ratio pairs were analyzed. The win ratio comparing edoxaban to no anticoagulation was 0.87 (95% CI: 0.68-1.10; P = 0.23). Most comparisons resulted in no clear winner (undecided pairs 84.9%). In the remaining comparisons, edoxaban won in 46% of the cases, placebo in 54%. Death and major bleeding were the most common events. The win odds was 0.98 (95% CI: 0.94-1.01; P = 0.23). CONCLUSIONS: This hypothesis-generating win ratio analysis, integrating death, thrombotic events, and major bleeds with and without quality of life, did not find an advantage of anticoagulation with edoxaban over no anticoagulation in patients with DDAF. The most common events were death and major bleeding.

Academy of the Romanian Scientists 'Carol Davila' University of Medicine Bucharest 050474 Romania

Atrial Fibrillation NETwork Muenster 48149 Germany

Biomedical Research Foundation Academy of Athens Greece and Hygeia Hospitals Group Athens 11527 Greece

Biostatistics Lab School of Medicine University of Crete Heraklion 71003 Greece

Cardiac Department John Radcliffe Hospital Oxford University Hospitals NHS Foundation Trust Oxford OX39DU United Kingdom

Cardiology Clinic St Anna University Hospital Medical University Sofia Sofia 1709 Bulgaria

Cardiology Department Fernando Fonseca Hospital Amadora 2720 276 Portugal

Cardiology Division European Georges Pompidou Hospital Paris 75908 France

Cardiology Unit Camposampiero Hospital AULSS Euganea Padua 35012 Italy

Centre for Patient Reported Outcomes Research Institute of Applied Health Research University of Birmingham Edgbaston Birmingham B15 2TT United Kingdom

Centro de Investigacion Biomedica en Red Cardiovascular Madrid 28029 Spain

City St George's University of London London EC1V 0HB United Kingdom

Danish Center for Health Services Research Department of Clinical Medicine Aalborg University Aalborg 9260 Denmark

Department of Cardiology and Intensive Care Medicine St Vincenz Hospital Paderborn Paderborn 33098 Germany

Department of Cardiology and Internal Diseases Medical University of Gdańsk Gdańsk 80 120 Poland

Department of Cardiology Esbjerg Hospital University Hospital of Southern Denmark Esbjerg 6700 Denmark

Department of Cardiology Heraklion University Hospital Heraklion Crete 71500 Greece

Department of Cardiology Institute for Clinical and Experimental Medicine Prague 14021 Czechia

Department of Cardiology School of Medical Sciences Faculty of Medicine and Health Örebro University Örebro 70182 Sweden

Department of Cardiology University Heart and Vascular Center Hamburg University Medical Center Hamburg Eppendorf Martinistr 52 Hamburg 20246 Germany

Department of Cardiology University Heart Center Medical University Graz Graz 8036 Austria

Department of Economics and Business Administration University of Applied Sciences Stralsund Stralsund 18435 Germany

Department of Internal Medicine 3 Cardiology and Angiology Innsbruck Medical University Innsbruck 6020 Austria

Department of Medical Science Uppsala University Uppsala 75185 Sweden

Department of Neuroepidemiology Institute for Medical Informatics Biometry and Epidemiology University Duisburg Essen Essen 45147 Germany

Department of Regional Health Research University of Southern Denmark Esbjerg 6700 Denmark

Departments of Cardiology and Physiology Maastricht University Maastricht 6200 MD The Netherlands

Faculty of Electrical Engineering and Computer Science Stralsund University of Applied Sciences Stralsund 18435 Germany

German Center for Cardiovascular Research Partner Site Hamburg Kiel Luebeck Postdamer Str 58 Berlin 10785 Germany

Heart and Vascular Centre Semmelweis University Budapest 1085 Hungary

Heart Center Department of Clinical and Experimental Cardiology Amsterdam Cardiovascular Sciences Amsterdam University Medical Centers University of Amsterdam Amsterdam 1105 AZ The Netherlands

Heart Rhythm Management Centre Postgraduate Program in Cardiac Electrophysiology and Pacing Universitair Ziekenhuis Brussel Vrije Universiteit Brussel European Reference Networks Guard Heart Brussels 1090 Belgium

Hospital Clinic Universtitat de Barcelona Barcelona Catalonia 08036 Spain

Institut d'Investigacions Biomèdiques Aigust Pi Sunyer Barcelona Catalonia 08036 Spain

Institute of Cardiovascular Sciences University of Birmingham Birmingham B152TT UK

Institute of Medical Biometry and Epidemiology University Medical Center Hamburg Eppendorf Hamburg 20246 Germany

Liverpool Centre for Cardiovascular Science at University of Liverpool Liverpool John Moores University and Liverpool Heart and Chest Hospital Liverpool L14 3PE United Kingdom

NIHR Birmingham Biomedical Research Centre and NIHR Applied Research Collaboration West Midlands University of Birmingham Edgbaston Birmingham B15 2TT United Kingdom

Otto von Guericke Universität Magdeburg Magdeburg 39106 Germany

doi: 10.1093/ehjqcco/qcaf125 PubMed

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