Newer anticoagulants may offer cognitive advantage in Alzheimer’s

Clinical takeaway: In patients with atrial fibrillation and Alzheimer’s disease, newer oral anticoagulants were associated with slower cognitive decline than warfarin or no anticoagulation.

Atrial fibrillation and Alzheimer’s disease commonly coexist, but whether anticoagulation affects cognitive decline after Alzheimer’s is established remains uncertain. In a large observational registry study, people taking newer oral anticoagulants had a modestly slower rate of cognitive decline than those taking warfarin or no anticoagulant.

The study included 7,308 people with Alzheimer’s disease and pre-existing atrial fibrillation. Of these, 1,690 were taking non-vitamin K oral anticoagulants (NOACs), 2,277 were taking warfarin, and 3,341 were not receiving anticoagulation. Cognitive function was tracked with the Mini-Mental State Examination (MMSE) for up to five years.

NOAC use was associated with a 0.23-point-per-year slower decline in MMSE scores compared with no anticoagulation and a 0.21-point-per-year slower decline compared with warfarin. Warfarin was not associated with slower cognitive decline compared with no anticoagulation. At five years, estimated MMSE scores were 15.3 with NOACs, 14.5 with warfarin, and 14.3 with no anticoagulation.

The clinical outcomes also favored NOACs. Compared with no anticoagulation, NOAC use was associated with lower rates of death, ischemic stroke or systemic embolism, and fracture, without a significant increase in major bleeding. Compared directly with warfarin, NOACs were associated with a 22% lower relative rate of ischemic stroke or systemic embolism and a 2.7-percentage-point lower three-year risk of major bleeding.

“The difference is modest for an individual patient from one year to the next, but over a longer period even such an effect could influence how cognitive function develops,” said Nanbo Zhu, researcher at Karolinska Institutet.

Source: Zhu N, et al. (2026 Aug 12) Eur Heart J. Oral anticoagulants, cognition, and clinical outcomes in atrial fibrillation and Alzheimer’s disease: a Swedish nationwide study