Abstract
Background: Currently, vitamin-K antagonists (VKAs) are the anticoagulant of choice for treating atrial fibrillation (AF) patients with valvular heart disease (VHD). Novel oral anticoagulants (NOACs) suggest better outcomes and could be a potential replacement for some patients. We aimed to conduct an updated systematic review and meta-analysis to resolve this matter. Methods: We queried MEDLINE, Embase and Cochrane central up until May 29, 2021 for studies comparing NOACs to VKAs in AF patients with VHD. Results from studies were presented as risk ratios (RR) with 95% confidence intervals (CI) and pooled using a random-effects model. Subgroup analysis by study design was performed to explore heterogeneity. Results: A total of 10 studies (4 RCTs and 6 retrospective observational) containing 196,124 patients (mean age 75.3 years; 54.0% men) were identified and included in the analysis. All 10 studies excluded patients with artificial valves while all 4 RCTS excluded moderate-to-severe mitral stenosis. Pooled analysis revealed significant risk reduction by NOACS of stroke or systemic embolism (RR 0.58 [95% CI 0.46, 0.74]; p<0.001, I 2 =91%), major bleeding (RR 0.60 [95% CI 0.43, 0.83]; p=0.002, I 2 =97%), intracranial hemorrhage (RR 0.40 [95% CI 0.28, 0.57]; p<0.001, I 2 =78%), all-cause mortality (RR 0.67 [95% CI 0.47, 0.96]; p=0.03, I 2 =97%) , myocardial infarction (RR 0.65 [95% CI 0.51, 0.84]; p=0.001, I 2 =0%), and major adverse cardiovascular events (RR 0.89 [95% CI 0.80, 0.99]; p=0.03, I 2 =0%). A significant difference was found upon subgroup analysis between RCTs and observational studies for all-cause mortality (p-value for interaction=0.005) Conclusions: NOACs were found to significantly reduce risk of all studied outcomes in patients with AF and VHD. Future RCTs are required to further validate these results.
Published Version
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