Abstract
BackgroundDirect oral anticoagulants (DOACs) are recommended as first-line anticoagulants in patients with atrial fibrillation (AF). However, in patients with cancer and AF the efficacy and safety of DOACs are not well established.ObjectiveWe performed a meta-analysis comparing available data regarding the efficacy and safety of DOACs vs vitamin K antagonists (VKAs) in cancer patients with non-valvular AF.MethodsAn online search of Pubmed and EMBASE libraries (from inception to May, 1 2020) was performed, in addition to manual screening. Nine studies were considered eligible for the meta-analysis involving 46,424 DOACs users and 182,797 VKA users.ResultsThe use of DOACs was associated with reduced risks of systemic embolism or any stroke (RR 0.65; 95% CI 0.52–0.81; p 0.001), ischemic stroke (RR 0.84; 95% CI 0.74–0.95; p 0.007) and hemorrhagic stroke (RR 0.61; 95% CI 0.52–0.71; p 0.00001) as compared to VKA group. DOAC use was associated with significantly reduced risks of major bleeding (RR 0.68; 95% CI 0.50–0.92; p 0.01) and intracranial or gastrointestinal bleeding (RR 0.64; 95% CI 0.47–0.88; p 0.006). Compared to VKA, DOACs provided a non-statistically significant risk reduction of the outcomes major bleeding or non-major clinically relevant bleeding (RR 0.94; 95% CI 0.78–1.13; p 0.50) and any bleeding (RR 0.91; 95% CI 0.78–1.06; p 0.24).ConclusionsIn comparison to VKA, DOACs were associated with a significant reduction of the rates of thromboembolic events and major bleeding complications in patients with AF and cancer. Further studies are needed to confirm our results.
Highlights
Electronic supplementary material The online version of this article contains supplementary material, which is available to authorized users.Extended author information available on the last page of the articleAtrial fibrillation (AF) is the most commonly diagnosed clinical arrhythmia and its prevalence increases with age, up to 18% at 85 years of age [1]
In 7 out 9 studies, major bleedings were considered according to the International Society of Thrombosis and Haemostasis (ISTH) criteria [24], whereas one study [20] reported any diagnosis of gastrointestinal, lung and urinary bleedings as safety outcomes
The main findings of our study are as follows: (1) Direct oral anticoagulants (DOACs) use resulted in lower rates of any stroke or systemic embolism, as compared to vitamin K antagonists (VKAs) use; (2) DOACs were associated with safer profile risk than VKAs, as the use of DOACs resulted in a statistically significant reduction of major bleedings and intracranial or gastrointestinal bleedings; (3) in comparison to VKAs, DOACs were found to be non-inferior for the outcomes myocardial infarction (MI), cardiovascular death, allcause death, major bleeding or non-major clinically relevant bleeding and any bleeding
Summary
Current European Heart Rhythm Association guidelines [13] recommend DOACs over VKAs as preferred anticoagulation strategy in patients with AF who are eligible for DOAC therapy. These recommendations cannot be extended to AF patients with malignances because in randomized clinical trials (RCTs) of DOACs for stroke and systemic embolism prevention in AF, cancer patients were underrepresented. Objective We performed a meta-analysis comparing available data regarding the efficacy and safety of DOACs vs vitamin K antagonists (VKAs) in cancer patients with non-valvular AF. Conclusions In comparison to VKA, DOACs were associated with a significant reduction of the rates of thromboembolic events and major bleeding complications in patients with AF and cancer.
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