Key result
Standard-dose DOACs cut stroke and SEE ~35% versus warfarin in Asians, exceeding benefits in non-Asians.
Why the study?
Randomized data comparing clinical outcomes of atrial fibrillation patients with Asian versus non-Asian races were limited.
Do direct oral anticoagulants improve clinical outcomes compared to warfarin to a greater extent in Asian versus non-Asian patients with atrial fibrillation?
Meta-Analysis (n=71,683)
Randomized
Yes
Do direct oral anticoagulants improve clinical outcomes compared to warfarin to a greater extent in Asian versus non-Asian patients with atrial fibrillation?
DOACs provide significantly greater relative reductions in stroke, systemic embolism, major bleeding, and net clinical outcomes compared to warfarin in Asian patients with atrial fibrillation than in non-Asian patients.
Answers are grounded in this paper and cite their sources.
SD DOACs reduce stroke/SEE more in Asians than non-Asians versus warfarin; confirms significant ethnic interaction in anticoagulant efficacy.
Background Randomized data comparing clinical outcomes of atrial fibrillation (AF) patients with Asian vs non-Asian races are limited. Methods Using the COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) database (data from RE-LY, ROCKET AF, ARISTOTLE, and ENGAGE AF-TIMI 48), we performed an individual patient-level meta-analysis to investigate and compare clinical outcomes of AF patients with self-defined Asian and non-Asian races adjusted for baseline characteristics. Standard-dose direct oral anticoagulants (SD DOAC) were defined as dabigatran 150mg bid; rivaroxaban 20mg (15mg) QD, apixaban 5 mg (2.5 mg) bid, or edoxaban 60 mg (30 mg) QD. Low-dose DOACs (DOACs [LD]) were defined as dabigatran 110 mg bid or edoxaban 30 mg (15mg) QD. Results There were 10,212 pts of Asian race and 61,471 non-Asian races in the COMBINE AF database. Compared with non-Asians, Asians were on average 3.2 yrs younger, 20 kg lighter, had worse renal function (mean CrCl 64.9 vs. 77.3 mL/min), and higher rates of prior stroke/transient ischemic attack (37.2% vs 26.6%), P<0.001 for each. The median value of time in therapeutic range of patients randomized to warfarin was lower in Asians than non-Asians (57.7% vs. 66.2%, P<0.001). In the warfarin arm, Asians had a higher adjusted risk of stroke/systemic embolic events (SEE), major bleeding (MB), ICH, GI bleeding (GIB), and net clinical outcome (NCO: stroke/SEE, MB, or death)(Figure; Upper panel). Compared to warfarin, SD DOACs significantly reduced the risks of stroke/SEE, MB, and NCO to a greater degree in Asians than non-Asians (HR stroke/SEE: Asians 0.65 vs Non-Asians 0.86; HR MB: Asians 0.62 vs Non-Asians 0.91; HR NCO: Asians 0.76 vs non-Asians 0.94; Pint <0.02 for each), while SD DOACs increased GIB only in non-Asians (Asian HR 0.92 [0.69-1.23] vs Non-Asians HR 1.41 [1.25-1.58], Pint 0.009; Figure Lower panel). Conclusions The adjusted risks of stroke/SEE and major bleeding with warfarin were higher in Asians compared to non-Asians. The benefits of DOACs over warfarin in preventing stroke/SEE, MB, and net clinical outcomes were significantly greater in Asians than non-Asians.
No takes yet. Share an insight, caveat, or question.
Chao et al. (2024) conducted a meta-analysis in Atrial fibrillation (n=71,683). Standard-dose direct oral anticoagulants (SD DOAC) vs. Warfarin was evaluated on Stroke/systemic embolic events (SEE) (HR 0.65 (Asians) vs 0.86 (non-Asians), p=Pint <0.02). Standard-dose DOACs compared to warfarin significantly reduced the risks of stroke/SEE, major bleeding, and net clinical outcomes to a greater degree in Asian patients than in non-Asian patients.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: