Effects of Non–Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation and Valvular Heart Disease: A Systematic Review and Meta‐Analysis

Abstract

BackgroundThe original non–vitamin K antagonist oral anticoagulant (NOAC) trials in nonvalvular atrial fibrillation (AF) enrolled patients with native valve pathologies. The object of this study was to quantify the benefit–risk profiles of NOACs versus warfarin in AF patients with native valvular heart disease (VHD).Methods and ResultsTrials were identified by exhaustive literature search. Trial data were combined using inverse variance weighting to produce a meta‐analytic summary hazard ratio (HR) and 95% confidence interval (CI) of efficacy and safety of NOACs versus warfarin. Our final analysis included 4 randomized controlled trials that enrolled 71 526 participants, including 13 574 with VHD. Pooling results from included trials showed that NOACs versus warfarin reduced stroke or systemic embolism (HR: 0.70; 95% CI, 0.60–0.82) and intracranial hemorrhage (HR: 0.47; 95% CI, 0.24–0.92) in AF patients with VHD. However, risk reduction of major bleeding and intracranial hemorrhage was driven by apixaban, edoxaban, and dabigatran (HR for major bleeding: 0.79 [95% CI, 0.69–0.91]; HR for intracranial hemorrhage: 0.33 [95% CI, 0.25–0.45]) but not rivaroxaban (HR for major bleeding: 1.56 [95% CI, 1.20–2.04]; HR for intracranial hemorrhage: 1.27 [95% CI, 0.77–2.10]).ConclusionsAmong patients with AF and native VHD, NOACs reduce stroke and systemic embolism compared with warfarin. Evidence shows that apixaban, dabigatran, and edoxaban also reduce bleeding in this patient subgroup, whereas major bleeding (but not intracranial hemorrhage or mortality rate) is significantly increased in VHD patients treated with rivaroxaban. NOACs are a reasonable alternative to warfarin in AF patients with VHD.

Efficacy and Safety of Non–Vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients With Impaired Liver Function: A Retrospective Cohort Study

“…However, such miscoding and misclassification are highly unlikely to be different between patients with normal liver function and those with ILF. The favorable efficacy and safety profiles of NOACs versus warfarin in patients with normal liver function were comparable to the results of meta‐analyses and real‐world data 32, 33, 34. Second, we did not analyze the quality of anticoagulation control as reflected by time in therapeutic range in the warfarin group, given the close relationship between the time in therapeutic range and thromboembolism or bleeding.…”

Oral anticoagulant use for stroke prevention in atrial fibrillation patients with difficult scenarios

“…Data from 2 meta-analyses pooling the results from the sub-analyses of the 4 major trials demonstrated that NOACs can reduce the risk of ischemic stroke in patients with AF and VHD compared with those with AF without VHD [39,40]. Based on these results, patients with AF and specific types of VHD are suitable for anticoagulation with NOACs.…”

Gastrointestinal Bleeding With the Use of New Oral Anticoagulants: Epidemiology, Risk Factors, Treatment, and Prevention

“…Они предотвращают развитие сосу-дистых тромбозов, которые являются веду-щей причиной «кардиоваскулярных катаст-роф» (инфаркта миокарда, ишемического ин-сульта, внезапной коронарной смерти), кото-рые наиболее часто становятся причиной ги-бели людей в развитых странах мира. Эти препараты неза-менимы в кардиологии, для профилактики осложнений сахарного диабета, при периферических заболеваниях со-судов (в частности, при тромбофлебите), в хирургической практике для профилактики послеоперационной тромбо-эмболии [1][2][3].…”

“…Эти препа-раты эффективнее, чем низкие дозы аспирина (НДА), и значительно удобнее в использовании, чем антагонисты витамина К (АВК), такие как варфарин, ведь действие вар-фарина наступает не сразу (через 5-7 дней), его эффект может существенно различаться у разных пациентов из-за генетического полиморфизма (в частности, по VKORC1 и CYP2C9), при его использовании нужно обязательно контролировать лабораторные показатели свертывания крови -протромбиновый индекс и международное норма-лизованное отношение (МНО), проводить «титрацию» до-зы. Для НОАК такой необходимости нет, поэтому они бы-стро завоевали популярность у врачей и с каждым годом все шире используются в реальной клинической практике [1][2][3].…”