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Suppah M, Kamal A, Saadoun R, Baradeiya AMA, Abraham B, Alsidawi S, Sorajja D, Fortuin FD, Arsanjani R. An Evidence-Based Approach to Anticoagulation Therapy Comparing Direct Oral Anticoagulants and Vitamin K Antagonists in Patients With Atrial Fibrillation and Bioprosthetic Valves: A Systematic Review, Meta-Analysis, and Network Meta-Analysis. Am J Cardiol 2023; 206:132-150. [PMID: 37703679 DOI: 10.1016/j.amjcard.2023.07.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/21/2023] [Accepted: 07/30/2023] [Indexed: 09/15/2023]
Abstract
Direct oral anticoagulants (DOACs) are a newer class of anticoagulants that inhibit factor Xa or factor IIa and include drugs such as rivaroxaban, apixaban, edoxaban, betrixaban, and dabigatran. Although vitamin K antagonists (VKAs) have been traditionally used to prevent thromboembolic events, DOACs have gained popularity because of their faster onset and offset of action and reduced need for monitoring. This study aimed to provide more data for anticoagulants in patients with atrial fibrillation with bioprosthetic heart valves by incorporating all available trials to date. A search was performed across 5 electronic databases to identify relevant studies. We analyzed the data using a pooled risk ratio for categorical outcomes and used the I2 test to determine heterogeneity. The quality of randomized controlled trials was assessed using the Cochrane risk of bias assessment tool, and the National Institutes of Health tool was used for observational studies. Our study included a frequentist network meta-analysis (MA) of the aggregate data to obtain the network estimates for the outcomes of interest. We retrieved 28 studies with a total of 74,660 patients with bioprosthetic heart valves. Our MA significantly showed that DOACs decrease the risk of all-cause bleeding (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.75 to 0.85, p >0.00001), stroke and systemic embolization (RR 0.89, 95% CI 0.80 to 0.99, p = 0.03), and intracranial bleeding outcomes (RR 0.62, 95% CI 0.45 to 0.86, p = 0.004) compared with VKA. In contrast, there was no significant difference between the compared groups in major bleeding (RR = 0.92, 95% CI 0.84 to 1.02, p = 0.10) and all-cause mortality outcomes (RR = 0.96, 95% CI 0.85 to 1.07, p = 0.43), respectively. In addition, the network MA results did not favor any of the studied interventions over each other (p <0.05) regarding all-cause bleeding, mortality, stroke and systemic embolization, and major bleeding outcomes. In conclusion, our study found that DOACs are more effective in reducing the risk of bleeding, stroke, systemic embolism, and intracranial bleeding than VKAs. However, no significant difference was observed in the incidence of gastrointestinal bleeding, major bleeding, thromboembolic events, and all-cause mortality. In addition, our network MA did not identify any specific DOAC treatment as more favorable than others.
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Affiliation(s)
- Mustafa Suppah
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Abdallah Kamal
- Department of Cardiology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Rakan Saadoun
- Department of Cardiology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, Pennsylvania
| | | | - Bishoy Abraham
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Said Alsidawi
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Dan Sorajja
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - F David Fortuin
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Reza Arsanjani
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
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Khodadadiyan A, Jazi K, Bazrafshan Drissi H, Bazroodi H, Mashayekh M, Sadeghi E, Gholamabbas G, Bazrafshan M, Rahmanian M. Direct oral anticoagulants versus vitamin K antagonists: Which one is more effective in atrial fibrillation. Perfusion 2023:2676591231202383. [PMID: 37697799 DOI: 10.1177/02676591231202383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
BACKGROUND The optimal approach for anticoagulation in patients with bioprosthetic valves and atrial fibrillation (AF) remains a subject of debate. A meta-analysis using updated evidence to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) in patients with AF and bioprosthetic valves to address this controversy. METHODS A comprehensive search was conducted in multiple databases, including PubMed, Scopus, Web of Science, ProQuest, and the Cochrane Central Register of Controlled Trials, up until March 2023. The search aimed to identify relevant randomized controlled trials (RCTs) that examined the efficacy and safety outcomes of both direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with bioprosthetic valves and atrial fibrillation. The primary outcomes of interest were major bleeding and all-cause mortality. RESULTS Our study demonstrated that despite the difference was not significant, the hazard of all-cause mortality was 2.5% higher in the DOAC group (HR = 1.03, 95% CI = [0.88, 1.19], p-value = .75). Similarly, the hazard of stroke (HR = 1.03, 95% CI = [0.87, 1.32], p-value = .71) and major bleeding (HR = 1.11, 95% CI = [0.89, 1.38], p-value = .36) were found to be respectively 3.2 and 10.7% higher in the DOAC group, although the difference was not significant. However, the hazard of intracranial hemorrhage was found to be 28.8 lower in the DOAC treatment group (HR = 0.71, 95% CI = [0.39, 1.31], p-value = .27), which again was not statistically significant. CONCLUSIONS Our meta-analysis demonstrates that in patients undergoing bioprosthetic valve surgery and presenting with AF afterward, DOAC and VKA are similar regarding life-threatening and all-cause mortality outcomes, including major bleeding, stroke, and intracranial hemorrhage.
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Affiliation(s)
| | - Kimia Jazi
- Student Research Committee, Faculty of Medicine, Medical University of Qom, Qom, Iran
| | | | - Helia Bazroodi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mina Mashayekh
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Erfan Sadeghi
- Research Consultation Center (RCC), Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ghazal Gholamabbas
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Bazrafshan
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Rahmanian
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Guardia Martínez P, Avilés Toscano AL, Martínez Mayoral MA, Moltó Miralles J. DOAC versus VKA in patients with atrial fibrillation and bioprosthetic valves: a systematic review and meta-analysis. Rev Esp Cardiol (Engl Ed) 2023; 76:690-699. [PMID: 36804556 DOI: 10.1016/j.rec.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/01/2023] [Indexed: 02/19/2023]
Abstract
INTRODUCTION AND OBJECTIVES Direct oral anticoagulant (DOAC) therapy has been shown to be safe and effective in patients with atrial fibrillation (AF). However, outcomes in AF patients with bioprosthetic valves are unclear, as this population has been underrepresented in clinical trials. The aim of this study was to assess the safety and efficacy of DOACs in this population based on the existing published literature. METHODS A systematic search and review were conducted to identify randomized clinical trials and comparative observational studies published from 2017 to January 2022 that compared DOACs and vitamin K antagonists (VKAs) in AF patients with bioprosthetic valves. Hazard ratios (HR) were collected to compare the 2 treatments in terms of cardiovascular and all-cause mortality, stroke/systemic embolism, and major bleeding. A meta-analysis combining the results was performed. RESULTS We included 12 studies (30 283 patients). DOACs and VKAs were compared based on HRs at the 95% confidence interval. DOAC therapy was associated with a significant 9% reduction in all-cause mortality (HR, 0.91; 95%CI, 0.85-0.97; P=.0068; I2=8%), with no significant differences in the risk of stroke/systemic embolism (HR, 0.87; 95%CI, 0.67-1.14; P=.29; I2=45%) or major bleeding (HR, 0.82; 95%CI, 0.67-1.00; P=.054; I2=48.7%). CONCLUSIONS DOAC therapy in AF patients with bioprosthetic valves may be associated with a significant reduction in all-cause mortality, with no reduction in the efficacy of stroke/systemic embolism prevention or increase in major bleeding risk.
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Affiliation(s)
| | | | | | - Josep Moltó Miralles
- Departamento de Estadística, Matemáticas e Informática, Universidad Miguel Hernández, Elche, Alicante, Spain
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Li D, Chang P, Zhang H, Bai F, Wu Q. The efficacy and safety of direct oral anticoagulants versus vitamin K antagonists in patients with left-sided bioprosthetic heart valves and atrial fibrillation: a systematic review and meta-analysis. Eur J Clin Pharmacol 2023; 79:461-471. [PMID: 36795127 DOI: 10.1007/s00228-023-03463-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND The efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) for the treatment of patients with left-sided bioprosthetic heart valves (BHV) and atrial fibrillation (AF) remain controversial. This study aims to perform a meta-analysis to evaluate the efficacy and safety of DOACs versus VKAs in this region. METHODS We retrieved all relevant randomized controlled studies and observational cohort studies, which critically assessed the efficacy and safety of DOACs versus VKAs among patients with left-sided BHV and AF in databases of PubMed, Cochrane, ISI Web of Sciences, and Embase. The efficacy outcomes of this meta-analysis were stroke events and all-cause death when the safety outcomes included major and any bleeding. RESULTS The analysis integrated 13 studies while enrolling 27,793 patients with AF and left-sided BHV. DOACs reduced the rate of stroke by 33% compared with VKAs (risk ratio [RR] 0.67; 95% CI 0.50-0.91), with no increased incidence of all-cause death (RR 0.96; 95% CI 0.82-1.12). For safety outcomes, major bleeding was reduced by 28% using DOACs rather than VKAs (RR 0.72; 95% CI 0.52-0.99), while there was no difference in the events of any bleeding (RR 0.84; 95% CI 0.68-1.03). In addition, in patients younger than 75 years old, the stroke rate was reduced by 45% in the population using DOACs (RR 0.55; 95% CI 0.37-0.84). CONCLUSION Our meta-analysis demonstrated that in patients with AF and BHV, compared with VKAs, using DOACs was associated with reduced stroke and major bleeding events without an increase of all-cause mortality and any bleeding. In the population younger than 75 years old, DOAC might be more effective in preventing cardiogenic stroke.
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Affiliation(s)
- Dong Li
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Peng Chang
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Hongliang Zhang
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Feng Bai
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Qiang Wu
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China.
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Klein T, Bignolas H, Mongardon N, Abou-Arab O, Guinot PG, Bouglé A, Guerci P. Practice Patterns of Antithrombotic Therapy during the Early Postoperative Course of Cardiac Surgery. J Clin Med 2023; 12. [PMID: 36902817 DOI: 10.3390/jcm12052029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/22/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND The current practices regarding the management of antithrombotic therapy during the early postoperative course of cardiac surgery are not well described. METHODS An online survey with multiple-choice questions was sent to cardiac anesthesiologists and intensivists from France. RESULTS The response rate was 27% (n = 149), with 2/3 of the respondents having less than 10 years of experience. A total of 83% of the respondents reported using an institutional protocol for antithrombotic management. A total of 85% (n = 123) of the respondents regularly used low-molecular-weight heparin (LMWH) during the immediate postoperative course. For 23%, 38%, 9%, and 22% of the physicians, LMWH administration was initiated between the 4th and 6th hour, between the 6th and 12th hour, between the 12th and 24th hour, and on postoperative day 1, respectively. The main reasons for not using LMWH (n = 23) were a perceived increased risk of perioperative bleeding (22%), poor reversal compared with unfractionated heparin (74%), local habits and the refusal of surgeons (57%), and its overly complex management (35%). The modalities of LMWH use were widely varied among the physicians. Chest drains were mostly removed within 3 days of surgery with an unchanged dose of antithrombotic therapy. Regarding temporary epicardial pacing wire removal anticoagulation, 54%, 30%, and 17% of the respondents left the dose unchanged, suspended the anticoagulation, or lowered the anticoagulation dose, respectively. CONCLUSION LMWH was inconsistently used after cardiac surgery. Further research is warranted to provide high-quality evidence regarding the benefits and safety of LMWH use early after cardiac surgery.
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Galliazzo S, Pelitti V, Campiotti L, Poli D, Squizzato A. Direct oral anticoagulants in patients with a left-sided bioprosthetic heart valve: a systematic review and meta-analysis. Intern Emerg Med 2023; 18:535-547. [PMID: 36746889 DOI: 10.1007/s11739-023-03208-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023]
Abstract
To compare the efficacy/effectiveness and safety of DOACs versus VKAs in patients with a previously and newly surgically implanted BHV with or without AF. A systematic search on MEDLINE and EMBASE was performed till November 2022. Treatment effects were estimated with relative risk (RR) and 95% confidence intervals (CIs). Statistical heterogeneity was assessed with the I2 statistic. Four randomized controlled trials (RCTs), 2 subgroup analysis from ARISTOTLE and ENGAGE-AF-TIMI 48 and 4 observational studies were included for a total of 5808 patients, 1893 on DOACs and 3915 on VKAs. AF prevalence was 98.28%. In the overall analysis, DOACs vs VKAs were associated with a RR for stroke/transient ischemic attack (TIA)/systemic embolism (SE) of 0.63 (95% CI 0.51-0.79; I2 = 0%) and a RR of major bleeding of 0.50 (95% CI 0.39-0.63; I2 = 0%) in a median follow-up of 19 months (IQR 4.5-33.4). In the 3 RCTs (DAWA, RIVER, ENAVLE), DOACs vs VKAs were associated with a RR of stroke/TIA/SE and major bleeding of 0.38 (95% CI 0.13-1.58, I2 = 0%) and of 0.68 (95% CI 0.32-1.44; I2 = 5%) respectively. In patients randomized during the first three months from valve surgery, DOACs vs VKAs were associated with a RR of stroke/TIA/SE and major bleeding of 0.54 (95% CI 0.14-2.08; I2 = 0%) and of 0.76 (95% CI 0.05-10.72; I2 = 66%). In previously implanted BHV patients with AF, DOACs showed a risk-benefit profile at least comparable to VKAs. DOACs showed a similar, even if underpowered, risk-benefit profile during the first three months after BHV implantation prevalently in patients with AF.
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Affiliation(s)
- Silvia Galliazzo
- Internal Medicine, Ospedale San Valentino-AULSS 2 Marca Trevigiana, Via Palmiro Togliatti, 1, 31044, Montebelluna, Treviso, Italy.
| | - Valentina Pelitti
- Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese and Como, Italy
| | - Leonardo Campiotti
- Department of Medicine and Surgery, ASST Settelaghi, University of Insubria, Varese, Italy
| | - Daniela Poli
- Thrombosis Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Alessandro Squizzato
- Research Center On Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
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Koh KK, Ling RR, Tan SYS, Chen Y, Fan BE, Shekar K, Sule JA, Subbian SK, Ramanathan K. Direct oral anticoagulants in atrial fibrillation following cardiac surgery: a systematic review and meta-analysis with trial sequential analysis. Br J Anaesth 2022; 129:154-162. [PMID: 35729010 DOI: 10.1016/j.bja.2022.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/08/2022] [Accepted: 05/03/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have been increasingly used as anticoagulation therapy in the postoperative period. However, their effectiveness in post-cardiac surgical atrial fibrillation is yet to be determined. METHODS We conducted a meta-analysis, searching three international databases from 1 January 2003 to 26 January 2022 for studies reporting on DOACs in at least 10 adult patients (>18 yr of age) with post-cardiac surgical atrial fibrillation. The primary outcomes were major neurological events (MNEs) and bleeding; secondary outcomes were mortality, hospital and ICU length of stay, cost, and other complications from therapy. We included studies of any design, including RCTs, cohort studies with and without propensity score matching methods, and single-armed case series. RESULTS Twelve studies (8587 DOACs; 8315 warfarin) were included in this meta-analysis. The incidences of postoperative bleeding and MNEs with DOACs were 7.3% (95% confidence interval [CI]: 3.4-14.7%) and 2.2% (95% CI: 0.9-4.9%), respectively. The incidence of MNEs was lower in high-risk patients, including those with hypertension and higher CHA2DS2-VASc score, whereas patients with prior transient ischaemic attack or stroke had higher incidence of bleeding. Trial sequential analysis revealed that the cumulative Z-curve crossed the conventional boundary of benefit. Compared with warfarin, DOACs reduced the risk of bleeding (relative risk [RR] 0.74; 95% CI: 0.62-0.89; P=0.0011) and MNEs (RR 0.63; 95% CI: 0.48-0.83; P=0.0012) but not mortality (RR 1.02; 95% CI: 0.77-1.35; P=0.090). CONCLUSIONS DOACs reduced bleeding and MNEs in patients with post-cardiac surgical atrial fibrillation, appearing safer than warfarin in this context. However, which DOAC provides the most effective anticoagulation in this patient population needs further investigation. CLINICAL TRIAL REGISTRATION PROSPERO CRD42021282777.
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Affiliation(s)
- Kylynn K Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ryan R Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shaun Y S Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ying Chen
- Agency for Science, Technology and Research, Singapore
| | - Bingwen E Fan
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, Prince Charles Hospital, Brisbane, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia; University of Queensland, Brisbane, QLD, Australia; Bond University, Gold Coast, QLD, Australia
| | - Jai A Sule
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, National University Hospital, Singapore
| | - Senthil K Subbian
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, National University Hospital, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore.
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Cao Y, Zheng Y, Li S, Liu F, Xue Z, Yin K, Luo J. An Updated Meta-Analysis of DOACs vs. VKAs in Atrial Fibrillation Patients With Bioprosthetic Heart Valve. Front Cardiovasc Med 2022; 9:899906. [PMID: 35783817 PMCID: PMC9248967 DOI: 10.3389/fcvm.2022.899906] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background Current guidelines recommend the utilization of direct-acting oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (AF). However, the optimal anticoagulation strategy for AF patients with bioprosthetic heart valves (BPHV) remains controversial. Therefore, we conducted this meta-analysis to explore the effect of DOACs versus vitamin K antagonists (VKAs) in this population. Methods We systematically searched the PubMed and Embase databases until November 2021 for studies reporting the effect of DOACs versus VKAs in AF patients with BPHV. Adjusted risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using the random-effects model with an inverse variance method. Results We selected four randomized clinical trials and seven observational studies (2236 DOAC- and 6403 VKAs-users). Regarding the effectiveness outcomes, there were no significant differences between DOACs and VKAs in stroke or systemic embolism (RR = 0.74, 95%CI: 0.50–1.08), ischemic stroke (RR = 1.08, 95%CI: 0.76–1.55), all-cause death (RR = 0.98, 95%CI: 0.86–1.12), and cardiovascular death (RR = 0.85, 95%CI: 0.40–1.80). In terms of the safety outcomes, DOACs was associated with lower risks of major bleeding (RR = 0.70, 95%CI: 0.59–0.82) and intracranial bleeding (RR = 0.42, 95%CI: 0.26–0.70), but the risks of any bleeding (RR = 0.85, 95%CI: 0.65–1.13) and gastrointestinal bleeding (RR = 0.92, 95%CI: 0.73–1.17) are not significantly different when compared with VKAs. The subgroup analysis with follow-up as a covariate revealed that the DOACs had lower risks of SSE (RR = 0.59, 95%CI: 0.37–0.94) and major bleeding (RR = 0.69, 95%CI: 0.58–0.81) in patients with a mean follow-up of more than 24 months, but no statistical differences were found in patients with the follow-up less than 24 months (SSE: RR = 1.10, 95%CI: 0.92–1.32; major bleeding: RR = 0.91, 95%CI: 0.42–2.01). Conclusions In AF with BPHV, patients on DOACs experienced a reduced risk of major bleeding and intracranial bleeding compared with VKAs, while the risks of stroke, cardiovascular death, and all-cause mortality were similar.
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Affiliation(s)
- Yalin Cao
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Yuxiang Zheng
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Siyuan Li
- Second Clinical Medical College, Nanchang University, Nanchang, China
| | - Fuwei Liu
- Department of Cardiology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
- *Correspondence: Fuwei Liu
| | - Zhengbiao Xue
- Department of Critical Care Medicine, the First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Kang Yin
- Department of Critical Care Medicine, the First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Jun Luo
- Department of Cardiology, The Affiliated Ganzhou Hospital of Nanchang University, Ganzhou, China
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Yokoyama Y, Briasoulis A, Ueyama H, Mori M, Iwagami M, Misumida N, Takagi H, Kuno T. Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and bioprosthetic valves: A meta-analysis. J Thorac Cardiovasc Surg 2021; 165:2052-2059.e4. [PMID: 34417050 DOI: 10.1016/j.jtcvs.2021.07.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The optimal anticoagulation strategy for patients with bioprosthetic valves and atrial fibrillation remains uncertain. We conducted a meta-analysis using updated evidence comparing direct anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with bioprosthetic valves and atrial fibrillation. METHODS Medline and Embase were searched through March 2021 to identify randomized controlled trials (RCTs) and observational studies investigating the outcomes of DOAC therapy and VKA therapy in patients with bioprosthetic valves and atrial fibrillation. The outcomes of interest were all-cause death, major bleeding, and stroke or systemic embolism. RESULTS Our analysis included 4 RCTs and 6 observational studies enrolling a total of 6405 patients with bioprosthetic valves and atrial fibrillation assigned to a DOAC group (n = 2142) or a VKA group (n = 4263). Pooled analysis demonstrated the similar rates of all-cause death (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.77-1.05; P = .18; I2 = 0%) in the DOAC and VKA groups. However, the rate of major bleeding was significantly lower in the DOAC group (HR, 0.66; 95% CI, 0.48-0.89; P = .006; I2 = 0%), whereas the rate of stroke or systemic embolism was similar in the 2 groups (HR, 0.72; 95% CI, 0.44-1.17; P = .18; I2 = 39%). CONCLUSIONS DOAC might decrease the risk of major bleeding without increasing the risk of stroke or systemic embolism or all-cause death compared with VKA in patients with bioprosthetic valves and atrial fibrillation.
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Affiliation(s)
- Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, Bethlehem, Pa
| | - Alexandros Briasoulis
- Division of Cardiovascular Diseases, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY
| | - Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Conn
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, Ky
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein Medical College, New York, NY.
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