Novel anticoagulants versus vitamin K antagonists for cardioversion of non- valvular atrial fibrillation \u2013 a meta-analysis of more than 17000 patients

Raluca Ileana Mincu,Amir Abbas Mahabadi,Matthias Totzeck,Tienush Rassaf

doi:10.1038/s41598-019-39925-5

Abstract

Non-vitamin K antagonist oral anticoagulants (NOACs) have proven a favorable risk-benefit profile compared to vitamin K antagonists (VKAs) for preventing stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF), but actual data are not sufficiently powered to extend this profile on patients with AF that undergo cardioversion. We aimed to compare outcomes after cardioversion of AF under NOACs vs. VKAs. We systematically searched Pubmed, Cochrane, SCOPUS, and Web of Science databases for studies published until October 2017. A total of 17506 patients from 11 studies were included. Treatment with NOACs was associated with similar relative risks (RR) of stroke and systemic embolism, hemorrhagic stroke, myocardial infarction, cardiovascular death, and all cause death compared to VKAs treatment. The RR of ischemic stroke was lower in the NOACs group. The risk of major bleeding was similar across treatment groups. Treatment with NOACs in patients with non-valvular AF that undergo cardioversion seems to be as safe and effective as the use of classical VKAs, with a better profile for ischemic stroke. Clinical Trial Registration: PROSPERO Registry, CRD42018086181 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID = 86181.

Highlights

The last years have brought substantial progress in the management of atrial fibrillation (AF), this arrhythmia continues to be one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity in the world[1]
The EMANATE study[15], comparing Non-vitamin K antagonist oral anticoagulants (NOACs) to vitamin K antagonists (VKAs) in anticoagulation naïve patients that underwent cardioversion, suggested, with the limitations of an underpowered study, that the use of apixaban lowers the risk of stroke compared with warfarin, with similar rates of bleeding across the groups
We performed a meta-analysis of the studies that compared outcomes of patients with non-valvular AF undergoing cardioversion treated with NOACs with patients treated with VKAs, aiming to (I) enrich statistical power for the evaluation of a potential non-inferiority of NOACs over VKAs, (II) compare data from randomized controlled trials (RCT) with large registry studies and (III) achieve sufficient sample size for evaluation of secondary outcome variables

Summary

Introduction

The last years have brought substantial progress in the management of atrial fibrillation (AF), this arrhythmia continues to be one of the major causes of stroke, heart failure, sudden death, and cardiovascular morbidity in the world[1]. The NOACs would be easier to manage for this group of patients, the actual data is not sufficiently powered to favor NOACs over VKAs in the setting of cardioversion, as it is for the general treatment of patients with AF and indication for anticoagulation[1]. We performed a meta-analysis of the studies that compared outcomes of patients with non-valvular AF undergoing cardioversion treated with NOACs with patients treated with VKAs, aiming to (I) enrich statistical power for the evaluation of a potential non-inferiority of NOACs over VKAs, (II) compare data from RCT with large registry studies and (III) achieve sufficient sample size for evaluation of secondary outcome variables

Objectives

Methods

Results

Conclusion