Dabigatran, Rivaroxaban, or Apixaban versus Warfarin in Patients with Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-Analysis of Subgroups

Background. New oral anticoagulants (NOAC; rivaroxaban, dabigatran, apixaban) have become available as an alternative to warfarin anticoagulation in non-valvular atrial fibrillation (NVAF). Methods. MEDLINE and CENTRAL, regulatory agencies websites, clinical trials registers and conference proceedings were searched to identify randomised controlled trials of NOAC versus warfarin in NVAF. Two investigators reviewed all studies and extracted data on patient and study characteristics along with cardiovascular outcomes. Relative risks (RR) and 95% confidence intervals (CI) were estimated using a random effect meta-analysis. Results. Three clinical trials in 50,578 patients were included. The risk of non-hemorrhagic stroke and systemic embolic events (SEE) was similar with the NOAC and warfarin (RR=0.93; 95% CI=0.83–1.04), while the risk of intracranial bleeding (ICB) with the NOAC was lower than with warfarin (RR = 0.46; 95% CI = 0.33–0.65). We found differences in the effect size on all strokes and SEE depending on geographic region as well as on non-hemorrhagic stroke, SEE, bleeding and mortality depending on time in therapeutic range. Conclusion. The NOAC seem no more effective than warfarin for prevention of nonhemorrhagic stroke and SEE in the overall NVAF population, but are generally associated with a lower risk of ICB than warfarin.

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Abstract 17301: Safety of Direct Oral Anticoagulants Compared to Warfarin for Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis

Circulation ◽

10.1161/circ.142.suppl_3.17301 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Ali Hage ◽

Daniel Dolan ◽

Viviane G Nasr ◽

Luis Castelo-Branco ◽

Daniel Motta-Calderon ◽

...

Keyword(s):

Atrial Fibrillation ◽

Clinical Trials ◽

Cardiac Surgery ◽

Hospital Readmission ◽

Lower Risk ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Secondary Outcome ◽

Systemic Embolization

Introduction: The evidence for use of direct oral anticoagulants (DOACs) in the management of post-operative cardiac surgery atrial fibrillation (POAF) is limited and mostly founded on clinical trials that excluded this patient population. Hypothesis: We performed a systematic review and meta-analysis of clinical trials and observational studies to evaluate the hypothesis that DOACs are safe compared to warfarin for the anticoagulation of patients with POAF. Methods: We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and the Cochrane Library for clinical trials and observational studies comparing DOAC with warfarin in patients ≥18 years old who had post-cardiac surgery atrial fibrillation. Primary outcomes included stroke, systemic embolization, bleeding, and mortality, with secondary outcome of hospital readmission. We performed a random-effects meta-analysis. Results: We found 3 clinical trials, 1 prospective and 12 retrospective cohort studies eligible for inclusion with a total of 10,538 patients (3,207 DOAC patients and 7,331 warfarin patients). The meta-analysis for the primary outcomes showed significantly lower risk of stroke with DOAC use (6 studies, 7143 patients, RR 0.64; 95% CI 0.50 to 0.81, I2: 0.0%) compared to warfarin, a trend towards lower risk of systemic embolization (4 studies, 7289 patients, RR 0.64, 95% CI 0.41 to 1.01, I2: 31.99%) and similar risks of bleeding (14 studies, 10182 patients, RR 0.91; 95% CI 0.74 to 1.10, I2: 26.6%) and mortality (12 studies, 9843 patients, relative risk [RR] 1.01; 95% CI 0.74 to 1.37, I2: 26.5%) The secondary outcome of hospital readmission had similar risk between groups. Conclusions: Current evidence suggests that DOACs, compared to warfarin, in the management of atrial fibrillation after cardiac surgery is associated with lower risk of stroke and a strong trend for lower risk of systemic embolization, and no evidence of increased risk for hospital readmission, bleeding or mortality.

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Association of smokeless tobacco and cerebrovascular accident: a systematic review and meta-analysis of global data

Journal of Public Health ◽

10.1093/pubmed/fdz054 ◽

2019 ◽

Vol 42 (2) ◽

pp. e150-e157 ◽

Cited By ~ 2

Author(s):

R Gupta ◽

S Gupta ◽

S Sharma ◽

D N Sinha ◽

R Mehrotra

Keyword(s):

Smokeless Tobacco ◽

Meta Analysis ◽

Random Effect ◽

Random Effect Model ◽

Group Analysis ◽

Chewing Tobacco ◽

Fatal Stroke ◽

Relative Risks ◽

Study Characteristics ◽

Gender Based

Abstract Background The association of smokeless tobacco (SLT) with stroke has been dealt with in only a few reviews. The present meta-analysis aims to present the updated comprehensive summary risk of stroke in adult SLT users along with sub group analysis. Methods A systematic literature search for articles evaluating risk of stroke in SLT users was conducted. The study characteristics and risk estimates were extracted independently by two authors (RG and SG). Random-effect model was used to estimate the summary relative risks. Results The overall risk of stroke in SLT users was found to be significantly higher (1.17, 95% CI 1.04–1.30) compared to non-users, especially for users in Southeast Asian region. The results remained unchanged even after strict adjustment for smoking (1.18, 95% CI 1.04–1.32). SLT users had 1.34 times or 13.4% higher risk of fatal stroke, though risk of nonfatal stroke was not enhanced. Significantly higher risk of stroke was seen in users of chewing tobacco (1.35, 95% CI 1.20–1.50) in comparison to non-chewers. Gender-based analysis showed enhanced risk of fatal stroke in both male and female users. SLT-attributable fraction of fatal stroke was highest for India at 14.8%. Conclusion The significant higher risk of stroke with SLT use, even after adjustment for smoking, emphasizes the imperative need to include SLT cessation advice for control and prevention of stroke.

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Systematic review and network meta-analysis of the relative efficacy and safety of edoxaban versus other nonvitamin K antagonist oral anticoagulants among patients with nonvalvular atrial fibrillation and CHADS2score ⩾ 2

SAGE Open Medicine ◽

10.1177/2050312115613350 ◽

2015 ◽

Vol 3 ◽

pp. 205031211561335 ◽

Cited By ~ 8

Author(s):

Maria M Fernandez ◽

Jianmin Wang ◽

Xin Ye ◽

Winghan Jacqueline Kwong ◽

Bintu Sherif ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Relative Efficacy ◽

Efficacy And Safety ◽

Nonvalvular Atrial Fibrillation

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New oral anticoagulants for nonvalvular atrial fibrillation with peripheral artery disease: a meta-analysis

Herz ◽

10.1007/s00059-020-04970-8 ◽

2020 ◽

Author(s):

Qiuyu Meng ◽

Zhifu Cen

Keyword(s):

Atrial Fibrillation ◽

Peripheral Artery Disease ◽

Meta Analysis ◽

Oral Anticoagulants ◽

New Oral Anticoagulants ◽

Peripheral Artery ◽

Nonvalvular Atrial Fibrillation ◽

Artery Disease

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Direct oral anticoagulants for stroke prevention in patients with atrial fibrillation: meta‐analysis by geographic region with a focus on European patients

British Journal of Clinical Pharmacology ◽

10.1111/bcp.13005 ◽

2016 ◽

Vol 82 (3) ◽

pp. 633-644 ◽

Cited By ~ 10

Author(s):

Antonio Gómez‐Outes ◽

Ana‐Isabel Terleira‐Fernández ◽

Gonzalo Calvo‐Rojas ◽

M. Luisa Suárez‐Gea ◽

Emilio Vargas‐Castrillón

Keyword(s):

Atrial Fibrillation ◽

Stroke Prevention ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Geographic Region

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Efficacy and Safety of Direct Oral Anticoagulants in Patients with Diabetes and Nonvalvular Atrial Fibrillation: Meta-Analysis of Observational Studies

Cardiovascular Therapeutics ◽

10.1155/2021/5520027 ◽

2021 ◽

Vol 2021 ◽

pp. 1-14

Author(s):

Bo Cao ◽

Xingcan Yao ◽

Lifang Zhang ◽

Xiaobo Hu ◽

Min Chen ◽

...

Keyword(s):

Myocardial Infarction ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Observational Studies ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Efficacy And Safety ◽

Nonvalvular Atrial Fibrillation ◽

Patients With Diabetes

Background. This meta-analysis was performed to compare the efficacy and safety of direct oral anticoagulants (DOACs) with vitamin K antagonists (VKAs) for stroke prevention in real-world patients with diabetes and nonvalvular atrial fibrillation (NVAF) through observational studies. Methods. PubMed, Embase, and Web of Science databases were searched up to August 2020 for eligible studies. Outputs were presented as risk ratios (RRs) and corresponding 95% confidence intervals (CIs) by using a random-effect model. Results. Seven observational studies involving 249,794 diabetic NVAF patients were selected. Compared with VKAs, the use of DOACs was associated with significantly reduced risks of stroke ( RR = 0.56 , 95% CI 0.45-0.70; p < 0.00001 ), ischemic stroke ( RR = 0.61 , 95% CI 0.48-0.78; p < 0.0001 ), stroke or systemic embolism (SSE) ( RR = 0.81 , 95% CI 0.68-0.95; p = 0.01 ), myocardial infarction ( RR = 0.69 , 95% CI 0.55-0.88; p = 0.002 ), major bleeding ( RR = 0.75 , 95% CI 0.63-0.90; p = 0.002 ), intracranial hemorrhage ( RR = 0.50 , 95% CI 0.44-0.56; p < 0.00001 ), and major gastrointestinal bleeding ( RR = 0.77 , 95% CI 0.62-0.95; p = 0.02 ), and a borderline significant decrease in major adverse cardiac events ( RR = 0.87 , 95% CI 0.75-1.00; p = 0.05 ) in NVAF patients with diabetes. Conclusion. For patients with NVAF and diabetes in real-world clinical settings, DOACs showed superior efficacy and safety profile over VKAs and significantly reduced risks of stroke, ischemic stroke, SSE, myocardial infarction, major bleeding, intracranial hemorrhage, and major gastrointestinal bleeding.

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