I commend Adamou and colleagues for their important meta-analysis, which reinforces the established superiority of direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for preserving renal function in patients with atrial fibrillation [1]. This work provides a valuable synthesis for clinicians navigating the complex intersection of cardiovascular and renal disease. However, while the study settles one debate, its granular data unearths a new, more nuanced challenge: a clinical paradox that questions the assumption of a uniform "class effect" among DOACs and demands a more precise approach to anticoagulant selection.
