Non–Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Asians With Atrial Fibrillation

Abstract

Background and Purpose— Several randomized trials and real-world studies have reported the efficacy and safety of non–vitamin K antagonist oral anticoagulants (NOACs) in Asian patients with atrial fibrillation; and therefore, this meta-analysis was aimed to compare the effects of NOACs with warfarin for atrial fibrillation stroke prevention in Asians. Methods— The PubMed and Embase databases were searched from January 2009 to February 2019 for studies on comparisons of NOACs versus warfarin in Asians. Risk ratios (RRs) with 95% CIs were pooled using a random-effects model. Results— Five NOAC trials and 21 observational cohorts were included. For the NOAC trials, compared with warfarin, NOACs was associated with reduced risks of stroke or systemic embolism (RR, 0.73; 95% CI, 0.59–0.90), all-cause death (RR, 0.83; 95% CI, 0.73–0.95), major bleeding (RR, 0.59; 95% CI, 0.48–0.72), and intracranial bleeding (RR, 0.36; 95% CI, 0.26–0.49). For the real-world data, compared with warfarin, NOACs was associated with decreased rates of stroke or systemic embolism (RR, 0.75; 95% CI, 0.68–0.82), ischemic stroke (RR, 0.70; 95% CI, 0.59–0.83), myocardial infarction (RR, 0.74; 95% CI, 0.58–0.93), all-cause death (RR, 0.67; 95% CI, 0.59–0.77), major bleeding (RR, 0.63; 95% CI, 0.55–0.73), intracranial bleeding (RR, 0.50; 95% CI, 0.43–0.59), and gastrointestinal bleeding (RR, 0.65; 95% CI, 0.51–0.84). The results did not change in the subgroup analyses based on the type and dose of NOACs. Conclusions— Based on published NOAC trials and real-world studies, the use of NOACs is noninferior to warfarin in Asians with atrial fibrillation irrespective of the NOAC type and dose.

The Impact of Novel Anticoagulants on the Upper Gastrointestinal Tract Mucosa

“…Similar results were shown in a meta-analysis of 43 studies (154,578 patients, RR 1.45) (Holster, 2013) [ 9 ]. On the contrary, later studies show a higher incidence of bleeding with warfarin than NOAC (Cangemi, 2017 [ 20 ], Xue, 2019 [ 21 ]). Another meta-analysis of 28 randomized trials (Miller, 2017) [ 15 ] including 129,357 patients did not reveal any difference in the incidence of GIT bleeding between NOACs overall and conventional anticoagulant therapy: Major bleeding (1.5% vs. 1.3%, respectively, RR 0.98, 95% CI, 0.80–1.21) and upper GIT bleeding (1.5% vs. 1.6%, respectively, RR 0.96, 95% CI, 0.77–1.20).…”

Adherence to the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline on the Use of Oral Anticoagulant Agents in Middle Eastern Patients with Atrial Fibrillation: The Jordan Atrial Fibrillation (JoFib) Study

“…Despite these worrying trends, we lack studies that address the clinical profiles, utilizing OACs according to contemporary guidelines and factors affecting the prescription patterns in a large cohort of patients in this region. Smaller studies from the Middle East and other regions have demonstrated a significant geographical heterogeneity in rates of adherence to the published guidelines in prescribing DOACs vs. VKAs for patients with AF [35][36][37]. Utilization of OAC in our study was closer to those reported from Western countries where the rate of use of OACs ranged between 34% and 85% of patients [5,8,38,39] with DOACs accounting for 41% of OACs [8] HAS-BLED score (mean ± SD) 1:5 ± 1:2 1 :7 ± 1:1 0.004 * Body mass index was measured in 1824 patients, left ventricular ejection fraction in 1888 patients, pulmonary hypertension in 1998 patients, and left ventricular hypertrophy in 1808 patients.…”

Association of Direct Oral Anticoagulants vs. Vitamin K Antagonists With Fractures in Atrial Fibrillation Patients: A Systematic Review and Meta-Analysis

“…The bias risk of each study was scored as “low,” “unclear,” or “high” risk in each section. The “low risk” was defined when three out of five biases were “low” ( 21 ). The Newcastle-Ottawa Scale (NOS) tool was applied to evaluate the methodological quality of observational studies.…”