Direct oral anticoagulants versus warfarin in nonvalvular atrial fibrillation patients with prior gastrointestinal bleeding: a network meta-analysis of real-world data

Hu, Wei; Cai, Huiya; Zhang, Jinhua

doi:10.1007/s00228-022-03300-7

Cited by 8 publications

(5 citation statements)

References 34 publications

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“…Recently, Suah et al ( 26 ) performed a subgroup analysis for AF patients with prior GIB and found that NOACs were associated with a reduced risk of ischemic stroke, major bleeding, and GIB compared with warfarin, only using the data by Garcia et al ( 17 ), Kwon et al ( 16 ), and Tapaskar et al ( 18 ). Additionally, a network meta-analysis comparing the effect of resuming NOACs and VKAs in AF patients with prior GIB demonstrated that the resumption of DOACs may be a safer therapy ( 13 ).…”

Section: Discussionmentioning

confidence: 99%

“…However, it was conducted primarily on patients taking VKAs, such as warfarin, and the population was not strictly limited to patients with AF. For patients with AF at a high risk of GIB, a recent network meta-analysis found that resumption of NOACs appeared to be the preferred option compared with warfarin ( 13 ). The European Society of Cardiology (ESC) Guidelines recommend that a VKA or another NOAC preparation should be preferred over dabigatran 150 mg two times daily, rivaroxaban 20 mg one time daily, or edoxaban 60 mg one time daily, although lacking strong evidence ( 14 ).…”

Section: Introductionmentioning

confidence: 99%

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Effectiveness and safety of oral anticoagulant therapy in patients with atrial fibrillation with prior gastrointestinal bleeding: A systematic review and meta-analysis

Zhao

Liu

et al. 2022

Front. Cardiovasc. Med.

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BackgroundGastrointestinal bleeding (GIB) commonly complicates anticoagulant therapy for patients with atrial fibrillation (AF). However, AF patients with prior GIB were excluded from most randomized controlled trials on anticoagulation therapy. Therefore, we conducted a systematic review and meta-analysis to assess the effect of oral anticoagulant (OAC) therapy in this specific population.MethodsRandomized trials and observational studies reporting the data about the resumption of OAC therapy among AF patients with prior GIB were included. The search was performed in the PubMed and Embase databasesup to March 2022. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled by a random-effects model with an inverse variance method.ResultsA total of 7 studies involving 57,623 patients were included. Compared with no anticoagulant therapy, OAC therapy was associated with decreased risks of stroke or systemic embolism (HR = 0.71, 95% CI: 0.59–0.84) and all-cause death (HR = 0.66, 95% CI: 0.60–0.72), but there was no significant difference in the risk of recurrent GIB (HR = 1.22, 95% CI: 0.94–1.59). Compared with vitamin K antagonists, non-vitamin K antagonist oral anticoagulants (NOACs) were associated with reduced risks of stroke or systemic embolism (HR = 0.61, 95% CI: 0.54–0.68), all-cause mortality (HR = 0.86, 95% CI: 0.75–0.99), major bleeding (HR = 0.75, 95% CI: 0.66–0.84), and GIB recurrence (HR = 0.83, 95% CI: 0.72–0.96).ConclusionsIn AF patients with prior GIB, OAC therapy (especially NOACs) demonstrated superior effectiveness compared with no anticoagulant therapy.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Effectiveness and safety of oral anticoagulant therapy in patients with atrial fibrillation with prior gastrointestinal bleeding: A systematic review and meta-analysis

Zhao

Liu

et al. 2022

Front. Cardiovasc. Med.

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“…In Ge-2022, low-dose dabigatran (110 mg twice daily) was associated with significantly lower rates of bleeding compared to warfarin (13.2 vs. 34.8%, P = 0.02) ( 22 ). Warfarin is more likely to cause recurrent bleeding than NOAC in patients with a history of gastrointestinal bleeding ( 28 ). In our study, nearly 45% of the patients had a history of gastrointestinal bleeding ( 21 ), which could contribute to an elevated level of bleeding in the warfarin group compared to the NOAC group.…”

Section: Discussionmentioning

confidence: 99%

Comparison of outcomes between novel oral anticoagulants and warfarin monotherapy in patients with left atrial appendage closure: A systematic review and meta-analysis

Sun

Chen²,

Gao³

et al. 2022

Front. Cardiovasc. Med.

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BackgroundPivotal trials of percutaneous left atrial appendage closure (LAAC) used dedicated post-procedure antithrombotic protocols. However, there is no consensus on the selection of new oral anticoagulants (NOAC) and warfarin monotherapy after LAAC. This study aims to compare NOAC with warfarin monotherapy for efficacy and safety in patients undergoing LAAC.MethodsA database search was conducted using PubMed, EMBASE, Cochrane Library, and Clinicaltrials.gov for trials that compared NOAC with warfarin monotherapy after LAAC. The effective outcomes included any major adverse events (all-cause death, stroke, major bleeding) and their individual components. Safety outcomes included all-cause death, major bleeding, total bleeding, DRT, and PDL >5 mm.ResultsWe included 10 non-randomized clinical trials with 10,337 patients, of whom 4,960 patients received NOAC, while 5,377 patients received warfarin. There were no statistically significant differences in any major adverse events (LogOR: −0.11, 95% CI: −0.27, 0.04, P = 0.16), stroke (LogOR: 0.00, 95% CI: −0.42, 0.42, P = 1.00), all-cause death (LogOR: −0.23, 95% CI: −0.48, 0.02, P = 0.07), major bleeding (LogOR: −0.22, 95% CI: −0.45, 0.01, P = 0.06). NOAC was associated with a significant reduction in total bleeding (LogOR: −1.01, 95% CI: −1.47, −0.55, P < 0.0001) compared to warfarin. No statistically significant differences were found in DRT (LogOR: −0.19, 95% CI: −0.15, 0.52, P = 0.27) and PDL >5 mm (LogOR: 0.19, 95% CI: −0.33, 0.72, P = 0.47). Meta-regression and subgroup analysis showed that total bleeding (LogOR: −1.56, 95% CI: −2.15, −0.97, P < 0.001) was significantly lower in the NOAC group in the subgroup of <75 y.ConclusionAfter LAAC, NOAC monotherapy was associated with a lower risk of bleeding compared to warfarin monotherapy for 45 days. There was no significant difference between NOAC and warfarin in terms of other results.Systematic review registrationwww.york.ac.uk/inst/crd, identifier: CRD42022361244.

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“…El meta-análisis más reciente a la fecha (Julio del 2022), fue el realizado por Hu et al (29), quienes realizaron un meta-análisis de redes con datos del mundo real, de pacientes anticoagulados ya sea con Warfarina o ACDO con FA, y antecedente de SGI. Los autores analizaron 10 estudios con un total de 59.244 individuos (27.793 reanudaron ACDO, 24.635 reanudaron Warfarina, y 6816 no reanudaron anticoagulación).…”

Section: Riesgo De Sangrado Gastrointestinal Con El Uso De Anticoagul...unclassified

“…Rivaroxaban, fue el único ACDO asociado con incremento del riesgo de SGI recurrente (HR 1.67; IC 95%, 1.16 -2.65). De manera global, reiniciar anticoagulación con cualquiera de los dos grupos, redujo el riesgo de morir por cualquier causa (ACDO: HR 0.57; IC 95%, 0.40 -0.84 vs. Warfarina: HR 0.58; IC 95%, 0.44 -0.79) (29). En este orden de ideas, se puede concluir que en la FA, utilizar tanto ACDO como Warfarina, contribuye a la reducción del riesgo de eventos tromboembólicos y ictus, pero los ACDO son superiores al evaluar la relación beneficioriesgo, siendo Apixaban a dosis de 5 mg dos veces al día la opción más segura, y Rivaroxaban a dosis de 20 mg, la opción con mayor riesgo de SGI.…”

Section: Riesgo De Sangrado Gastrointestinal Con El Uso De Anticoagul...unclassified

Riesgo de sangrado gastrointestinal por uso de anticoagulantes directos orales: ¿cuál es más seguro?

Lozada Martinez,

Solano Díaz,

Barbosa Pérez

et al. 2022

rev cuarzo

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Los anticoagulantes directos orales fueron agentes que cambiaron radicalmente la estrategia de anticoagulación, sobre todo en el manejo del riesgo cardiovascular e incidencia de eventos tromboembólicos. No obstante, de acuerdo a su mecanismo de acción, era imperativo el riesgo de sangrado como evento adverso. El sangrado gastrointestinal es una de las localizaciones más frecuentes asociadas a estos eventos, el cual, de acuerdo al estado del paciente, puede comprometer el estado hemodinámico, endocrino y funcional del paciente. Por lo tanto, esta es una condición que acarrea elevados costos en salud, afecta la calidad de vida del paciente y es un potencial desencadenante de morbilidad y mortalidad. Distintos factores de riesgo pueden contribuir al incremento del riesgo de sangrado, y es un reto sopesar la relación beneficio-riesgo y costo-efectividad. Existen brechas respecto a los perfiles de seguridad y eficacia en la actualidad, puesto que estudios recientes han encontrado variabilidad del rendimiento de estos medicamentos, considerando algunos análisis por subgrupos. Considerando lo anterior, el objetivo de esta revisión consiste en sintetizar evidencia sobre los perfiles de eficacia y seguridad de los anticoagulantes directos orales, en pacientes con antecedente o no de sangrado gastrointestinal, y ciertos subgrupos, quienes requieren de manera obligatoria esta terapia. Se llevó a cabo una búsqueda bibliográfica en las bases de datos PubMed, ScienceDirect, Embase, EBSCO y MEDLINE. Revisiones recientes sobre este tema, han descrito varios factores que pueden influir sobre el riesgo de sangrado gastrointestinal con el uso de anticoagulantes directos orales, algunos modificables, otros no modificables, los cuales deben tenerse en cuenta en la práctica clínica, como lo son: edad avanzada (> 75 años), elevadas dosis de anticoagulación, uso concomitante de esteroides, antiagregantes plaquetarios y antiinflamatorios no esteroideos, antecedente de sangrado gastrointestinal, etnia, y disminución de la función renal, entre otros. Y a pesar que la evidencia es heterogénea, y aunque parece ser que los anticoagulantes directos orales demuestran ser superiores a la Warfarina, existen algunos que revelan un perfil de seguridad y eficacia mejor que otros. Parece ser que Apixaban en dosis de 5 mg dos veces al día es el agente farmacológico de este grupo más seguro, mientras que Rivaroxaban es el agente que exhibe mayor riesgo de sangrado gastrointestinal. Estos resultados, son similares tanto de manera general, como en pacientes con fibrilación auricular, donde es más difícil sopesar la relación beneficio-riesgo.

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Direct oral anticoagulants versus warfarin in nonvalvular atrial fibrillation patients with prior gastrointestinal bleeding: a network meta-analysis of real-world data

Cited by 8 publications

References 34 publications

Effectiveness and safety of oral anticoagulant therapy in patients with atrial fibrillation with prior gastrointestinal bleeding: A systematic review and meta-analysis

Effectiveness and safety of oral anticoagulant therapy in patients with atrial fibrillation with prior gastrointestinal bleeding: A systematic review and meta-analysis

Comparison of outcomes between novel oral anticoagulants and warfarin monotherapy in patients with left atrial appendage closure: A systematic review and meta-analysis

Riesgo de sangrado gastrointestinal por uso de anticoagulantes directos orales: ¿cuál es más seguro?

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