"A Tale of Two Cities": Anticoagulation Management in Patients with Atrial Fibrillation and Prosthetic Valves in the Era of Direct Oral Anticoagulants

Long-Term Outcomes of Mechanical Versus Bioprosthetic Aortic Valve Replacement: A Systematic Review and Meta-Analysis

This study aimed to investigate the safety and efficacy of bioprosthetic (BV) versus mechanical valves (MV) on long-term outcomes in 50- to 70-year-old aortic stenosis (AS) patients. A literature search for articles published until April 2023 yielded 13 eligible studies, with 15,320 patients divided into BV (n = 7,320) and MV (n = 8,000) cohorts. The review was registered prospectively with PROSPERO (CRD42021278777). MV demonstrated a favorable hazard ratio (HR: 1.12, 95% CI: 1.00-1.25, I2 = 60%) and higher survival rates at 5 (OR:1.13, 95% CI: 1.02-1.25, I2 = 42%) and 10 years (OR: 1.13, 95% CI: 1.05-1.23, I2 = 0%). At 15 years, stroke incidence was comparable (OR: 1.12, 95% CI: 0.98-1.27, I2 = 4%). BV showed lower bleeding events (OR: 1.7, 95% CI: 1.18-2.46, I2 = 88%), but MV replacement showed lower reoperation incidence (OR: 0.27, 95% CI: 0.18-0.42, I2 = 85%). MV appears favorable for the long-term approach in AS management compared to BV.

Practice-derived data on non-vitamin K antagonist oral anticoagulant therapy to complement observations from randomized trials

Anticoagulation is fundamental in the management of patients with atrial fibrillation (AF). The study aims to provide a comparative review of the major phase III randomized clinical trials (RCTs) and real-world data (RWD) from reliable, high-grade Phase IV studies that assess the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) vs. vitamin K antagonists (VKAs). Observational studies based on nationwide or health insurance database records on the use of NOACs vs. VKAs in patients with AF were included. We performed a comparison of the efficacy and safety characteristics associated with NOACs vs. VKAs in RCTs and RWD. Although RCTs provide strong support for evidence-based practice, RWD may be used to reflect the broader picture of various clinical settings, provide supplementary insight and fulfil knowledge gaps. Both study types confirmed the safety and efficacy of NOACs in preventing stroke and thromboembolism in patients with AF. In comparison to VKAs, NOACs were associated with reduced risk of ischaemic events and lower rates of adverse events such as major bleeding or intracranial haemorrhage. Administration of NOACs might be associated with increased risk of dose-related gastrointestinal bleeding and myocardial ischaemic events, especially in the early treatment period after switching from VKAs. Special care should be taken in challenging clinical situations like severe renal or hepatic impairment when the treatment regimen needs to be considered individually. Randomized clinical trial and RWD studies are complementary and present comparable findings, affirming that NOACs are safe and effective for anticoagulation of patients with AF in daily clinical practice.