Direct Oral Anticoagulants vs. Vitamin K Antagonists in Atrial Fibrillation Patients at Risk of Falling: A Meta-Analysis

Abstract

BackgroundDirect oral anticoagulants (DOACs) and warfarin are usually used for people with atrial fibrillation (AF). However, for the AF patients at risk of falling, the effectiveness and safety outcomes of DOACs compared with warfarin remain unclear. Therefore, we performed a meta-analysis regarding the effectiveness and safety of DOACs vs. warfarin in AF patients at risk of falling.MethodsA search of the PubMed and Embase databases until November 2021 was performed. We included studies if they satisfied the following criteria: (1) study type: randomized clinical trials or observational cohort studies. (2) Comparisons: effectiveness and/or safety of DOACs (dabigatran, rivaroxaban, apixaban, or edoxaban) compared with warfarin. (3) Study data: the sample size, the number of events in the VKAs or DOACs groups, adjusted risk ratios (RRs), and 95% confidence intervals (CIs). (4) Study outcomes: stroke or systemic embolism (SSE), ischemic stroke, myocardial infarction (MI), all-cause death, and cardiovascular death; major bleeding, major or clinically relevant non-major (CRNM) bleeding, intracranial bleeding, gastrointestinal bleeding, and any bleeding. (5) Study population: patients at risk of falling. According to the Morse Fall Scale, the risk of falling relates to the history of falling, secondary diagnosis, ambulatory aids, intravenous therapy, type of gait, and mental status. In this meta-analysis, if the patient's MFS score is ≥25 points, he will be thought of as having the risk of falling. The adjusted risk ratios (RRs) and 95% confidence intervals (CIs) were pooled by a random-effects model with an inverse variance method.ResultsThree cohort studies were included in our study. For the effectiveness outcomes, the use of DOACs was only associated with a significantly reduced risk of hemorrhagic stroke (RR = 0.28, 95%CI:0.10–0.75) compared with warfarin, but there were no significant differences in stroke or systemic embolism (SSE) (RR = 0.87, 95%CI:0.70–1.08), cardiovascular death (RR = 0.97, 95%CI:0.73–1.29) and all-cause death (RR = 0.90, 95%CI:0.72–1.11). For the safety outcomes, the use of DOACs was significantly associated with reduced risks of major or clinically relevant non-major bleeding (RR = 0.77, 95%CI:0.61–0.98) and intracranial bleeding (RR = 0.26, 95%CI:0.11–0.66) but not major bleeding (RR = 0.78, 95%CI:0.58–1.06).ConclusionsCompared with warfarin, the use of DOACs in AF patients at risk of falling is significantly associated with reduced risks of hemorrhagic stroke, major or clinically relevant non-major bleeding, and intracranial bleeding.

Clinical outcomes in patients with atrial fibrillation and a history of falls using non-vitamin K antagonist oral anticoagulants: A nationwide cohort study

“…The benefit-risk profile of NOACs was maintained in AF patients with a history of falls, in line with observations from post-hoc analyses of the ARISTOTLE [8] and ENGAGE AF-TIMI 48 trial [12] and one observational cohort study [18] . However, differences in stroke/SE, all-cause mortality or major bleeding risks were not significantly different between NOACs and VKAs in these studies [8] , [12] , [18] nor after pooling results in meta-analyses [40] , [41] , due to the limited number of subjects at risk and events. By including a large number of AF patients with a history of falls during long-term follow-up, we could demonstrate that NOACs were associated with a 30%, 41% and 17% significantly reduced risk of stroke/SE, ischemic stroke and all-cause mortality compared to VKAs respectively, while the risks of major and gastrointestinal bleeding were similar, which should be considered as an important contribution to the current evidence and also as a helpful guidance for clinical practice.…”