Effectiveness and Safety of DOACs vs. Warfarin in Patients With Atrial Fibrillation and Frailty: A Systematic Review and Meta-Analysis

Abstract

BackgroundPatients with atrial fibrillation (AF) and frailty are a considerable group in clinical practice. However, existing studies provide insufficient evidence of anticoagulation strategies for these patients. Therefore, we conducted a meta-analysis to determine the effectiveness and safety outcomes of direct oral anticoagulants (DOACs) for these patients.MethodsRandomized controlled trials or observational studies reporting the data about the DOACs and warfarin therapy among frail AF patients were included. The search was performed in the PubMed and Embase databases up to March 2022. Frailty was defined using the most widely used claims-based frailty index or the cumulative deficit model-based frailty index.ResultsA total of 4 studies involving 835,520 patients were included. Compared with warfarin, DOACs therapy reduced the risks of stroke or systemic embolism (HR = 0.79, 95%CI: 0.69–0.90), ischemic stroke (HR = 0.79, 95%CI: 0.71–0.87), hemorrhagic stroke (HR = 0.52, 95%CI: 0.35–0.76), and all-cause death (HR = 0.90, 95%CI: 0.84–0.96). In safety outcomes, DOACs was significantly associated with reduced risks of major bleeding (HR = 0.79, 95%CI: 0.64–0.97) and intracranial hemorrhage (HR = 0.58, 95%CI: 0.52–0.65) compared to warfarin, but there were no statistically differences in gastrointestinal bleeding (HR = 0.97, 95%CI: 0.73–1.29).ConclusionsDOACs exerted superior effectiveness and safety outcome than warfarin in AF patients with frailty.

Discontinuation of oral anticoagulant use among nursing home residents with atrial fibrillation before hospice enrollment

“…Residents with advanced age were more likely to discontinue warfarin but less likely to discontinue DOACs. This may reflect the absence of a need for routine monitoring and better safety profile with certain DOACs, most notably apixaban, which may provide residents and their care team with some confidence that OAC continuation is unlikely to adversely affect their quality of life 47,48 . However, most associations were similar in stratified analyses examining DOAC and warfarin discontinuation separately, suggesting that other factors we studied play a similar role in decisions to discontinue these OACs.…”

The Effect of Direct Oral Anticoagulant Therapy (DOACs) on oral surgical procedures: a systematic review

“…Nevertheless, a sufficient gap was maintained between the last dose of DOAC and the dental procedure to minimize the risk of postoperative bleeding. Zeng et al, while comparing the effectiveness and safety outcomes of DOACs with warfarin in patients with atrial fibrillation, concluded that DOACs exerted superior effectiveness and were associated with a significant reduction in severe bleeding and intracranial hemorrhage [ 42 ]. DOACs exert their action by reversibly inhibiting the action of coagulation factors, such as thrombin or factor Xa.…”

Impact of anticoagulants on the clinical outcomes of colonic diverticular bleeding comparing warfarin and direct oral anticoagulants

“…Consequently, DOACs have recently, been used widely as the standard treatment for nonvalvular AF (NVAF). Growing evidence has supported the superiority or noninferiority of DOACs to warfarin for their antithrombotic effect and reduced bleeding risk 16 . While previous studies, including the RE-LY 4 , ROCKET-AF 6 , ARISTOTLE 5 , and ENGAGE AF-TIMI 48 17 trials, have reported equal or lower frequencies of major bleeding or intracranial hemorrhage in AF patients receiving DOACs compared with those on dose-adjusted warfarin, they have concluded that there was statistically significant increase in GI bleeding in patients receiving DOACs.…”