Comparison of the Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation and Valvular Heart Disease: Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Bitar, Yasmin de Souza Lima; Durães, André Rodrigues; Roever, Leonardo; Neto, Mansueto Gomes; Lins-Kusterer, Liliane; Bocchi, Edimar Alcides

doi:10.3389/fcvm.2021.712585

“…The most feared bleeding event associated with the use of OACs in patients with AF is intracranial hemorrhage, which occurred in 9 (0.5%) patients at one year in the current study. This low rate and the low rate of major bleeding events (2.6%) are both reassuring and are in line with the results of other regional studies [ 26 , 34 , 36 ]. The burden of hospitalizations in patients with AF is a major source of an escalating health-care cost.…”

Section: Resultssupporting

confidence: 89%

“…This is a universal finding reported by other investigators and is explained by the global improved life expectancy and the increasing prevalence of CV risk factors that contribute to the pathogenesis of NVAF [ 4 – 6 , 25 ]. Patients with NVAF in this study had high prevalence of CV risk factors and comorbidities; findings reflected by a mean CHA2DS2-VASc score are higher than that reported by the DOACs phase III clinical trials [ 26 ]. Despite reports of the notoriously suboptimal rates of utilization of, adherence to, and early discontinuation of OACs in NVAF patients [ 27 , 28 ], we observed a reassuring high rate of utilization of OACs at enrollment and high rate of adherence to these medications at one year.…”

Section: Resultsmentioning

confidence: 69%

One-Year Clinical Outcome in Middle Eastern Patients with Atrial Fibrillation: The Jordan Atrial Fibrillation (JoFib) Study

Hammoudeh

¹

,

Khader

²

,

Tabbalat

³

et al. 2022

International Journal of Vascular Medicine

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Background. Prevention of stroke and systemic embolism (SE) prevention in patients with atrial fibrillation (AF) has radically changed in recent years. Data on contemporary utilization of oral anticoagulants (OACs) and cardiovascular outcome in Middle Eastern patients with AF are needed. Methods. The Jordan atrial fibrillation (JoFib) study enrolled consecutive patients with AF in Jordan from May 2019 through October 2020 and were followed up for one year after enrollment. Results. Overall, 2020 patients were enrolled. The mean age was 67.9 + 13.0 years. Nonvalvular (NVAF) was diagnosed in 1849 (91.5%) patients. OACs were used in 85.7% of high-risk patients with NVAF (CHA2DS2-VASc score>3 in women, and>2 in men), including direct OACs (DOACs) in 64.1% and vitamin K antagonists (VKA) in 35.9%. Adherence rate to the use of the same OAC agent was 90.6% of patients. One-year cardiovascular (CV) mortality was 7.8%, stroke/SE was 4.5%, and major bleeding events were 2.6%. Independent predictors for all-cause mortality in patients with NVAF were age>75 years, heart failure, major bleeding event, type 2 diabetes mellitus, study enrollment as an in-patient, and coronary heart disease. The use of OACs was associated with lower all-cause mortality. The strongest independent predictors for stroke/SE were high-risk CHA2DS2-VASc score and prior history of stroke. Conclusions. This study of Middle Eastern AF patients has reported high adherence to OACs. The use of OACs was associated with a lower risk for all-cause mortality. One-year rates of stroke and major bleeding events were comparable to those reported from other regions in the world.

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“…In fact, if we consider the much higher level of evidence shown in meta-analyses of randomized controlled trials, DOACs have been associated with reductions in stroke, ICH, fatal bleeding, and all-cause mortality compared with warfarin. 3,4 Only gastrointestinal bleeding was increased, while ICH, a devastating cause of death and disability, was reduced by more than 50%. 5 The 2020 Canadian Cardiovascular Society guidelines recommend DOACs for anticoagulation in nonvalvular atrial fibrillation and, additionally, switching to these agents from warfarin wherever possible.…”

mentioning

confidence: 99%

Anticoagulation in patients with nonvalvular atrial fibrillation

Bosomworth

¹

2023

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Letters } CorrespondanceAnticoagulation in patients with nonvalvular atrial fibrillation D r Murray B. Trusler's letter in the April 2023 issue of Canadian Family Physician 1 concerned teambased care to improve time in therapeutic range with the use of warfarin. He documents how the use of ancillary personnel and new technologies can successfully ease the burden of anticoagulation monitoring in primary care. While the newer direct oral anticoagulants (DOACs) can obviate this burden, these drugs are often inaccessible to those of lower income in our increasingly inequitable society.Dr Trusler goes on to say that DOACs have failed to reduce the incidence of stroke and systemic embolism compared with warfarin. He cites a Canadian retrospective cohort study by Durand et al 2 as evidence. What is not mentioned is that the same study found an association with reduced major bleeding, intracranial hemorrhage (ICH), and all-cause mortality with DOAC use. In fact, if we consider the much higher level of evidence shown in meta-analyses of randomized controlled trials, DOACs have been associated with reductions in stroke, ICH, fatal bleeding, and all-cause mortality compared with warfarin. 3,4 Only gastrointestinal bleeding was increased, while ICH, a devastating cause of death and disability, was reduced by more than 50%. 5 The 2020 Canadian Cardiovascular Society guidelines recommend DOACs for anticoagulation in nonvalvular atrial fibrillation and, additionally, switching to these agents from warfarin wherever possible. 6 An approach to use of these guidelines appears in the same issue of the journal. 7 Those who must continue taking warfarin will, of course, greatly benefit from a team-based approach to monitoring.-N. John Bosomworth MD CCFP FCFP Vancouver, BC

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“…In fact, if we consider the much higher level of evidence shown in meta-analyses of randomized controlled trials, DOACs have been associated with reductions in stroke, ICH, fatal bleeding, and all-cause mortality compared with warfarin. 3,4 Only gastrointestinal bleeding was increased, while ICH, a devastating cause of death and disability, was reduced by more than 50%. 5 The 2020 Canadian Cardiovascular Society guidelines recommend DOACs for anticoagulation in nonvalvular atrial fibrillation and, additionally, switching to these agents from warfarin wherever possible.…”

mentioning

confidence: 99%

President’s Message on target

Perkin¹

2023

Can Fam Physician

0

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Letters } CorrespondanceAnticoagulation in patients with nonvalvular atrial fibrillation D r Murray B. Trusler's letter in the April 2023 issue of Canadian Family Physician 1 concerned teambased care to improve time in therapeutic range with the use of warfarin. He documents how the use of ancillary personnel and new technologies can successfully ease the burden of anticoagulation monitoring in primary care. While the newer direct oral anticoagulants (DOACs) can obviate this burden, these drugs are often inaccessible to those of lower income in our increasingly inequitable society.Dr Trusler goes on to say that DOACs have failed to reduce the incidence of stroke and systemic embolism compared with warfarin. He cites a Canadian retrospective cohort study by Durand et al 2 as evidence. What is not mentioned is that the same study found an association with reduced major bleeding, intracranial hemorrhage (ICH), and all-cause mortality with DOAC use. In fact, if we consider the much higher level of evidence shown in meta-analyses of randomized controlled trials, DOACs have been associated with reductions in stroke, ICH, fatal bleeding, and all-cause mortality compared with warfarin. 3,4 Only gastrointestinal bleeding was increased, while ICH, a devastating cause of death and disability, was reduced by more than 50%. 5 The 2020 Canadian Cardiovascular Society guidelines recommend DOACs for anticoagulation in nonvalvular atrial fibrillation and, additionally, switching to these agents from warfarin wherever possible. 6 An approach to use of these guidelines appears in the same issue of the journal. 7 Those who must continue taking warfarin will, of course, greatly benefit from a team-based approach to monitoring.-N. John Bosomworth MD CCFP FCFP Vancouver, BC

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Comparison of the Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation and Valvular Heart Disease: Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Cited by 3 publications

References 38 publications

One-Year Clinical Outcome in Middle Eastern Patients with Atrial Fibrillation: The Jordan Atrial Fibrillation (JoFib) Study

One-Year Clinical Outcome in Middle Eastern Patients with Atrial Fibrillation: The Jordan Atrial Fibrillation (JoFib) Study

Anticoagulation in patients with nonvalvular atrial fibrillation

President’s Message on target

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