Key result
Direct oral anticoagulants demonstrated effectiveness in preventing thromboembolism in patients with atrial fibrillation and mitral or aortic stenosis, though further large-scale randomized clinical trials are needed to confirm these findings.
Why the study?
Several studies had summarized DOAC performance in AF patients with mitral or aortic stenosis, and an updated clinical review was needed to guide management in this specific population.
Systematic Review (n=5,993)
May support DOAC use in mitral stenosis with AF; leaves open need for RCTs in aortic stenosis.
Background: Several studies have summarized the clinical performance of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) patients with mitral stenosis or aortic stenosis. The significance of this review was to provide clinicians the latest update of the clinical application of DOACs in managing this specific population. Methods: Literatures from the PubMed database up to July 2022 were screened for inclusion. Studies on the effect of DOACs in patients suffering from AF with mitral or aortic stenosis were assessed for further selection. Results: Results from four studies were gathered: the RISE MS trial, the DAVID-MS study, and two observational studies. In the Korean observational study with a 27-month follow-up duration and a sample population consisted of patients with mitral stenosis and AF, the thromboembolic events happened at a rate of 2.22%/ year in the DOAC group and 4.19%/year in the warfarin group (adjusted hazard ratio: 0.28; 95% CI: 0.18-0.45). Intracranial hemorrhage occurred at rates of 0.49% and 0.93% in the DOAC and the warfarin groups, respectively (adjusted hazard ratio: 0.53; 95% CI: 0.22-1.26). In the Danish observational study, which had a sample pool with AF patients with aortic stenosis, reported that the adjusted hazard ratios for thromboembolism and major bleeding were 1.62 (95% CI, 1.08-2.45) and 0.73 (95% CI, 0.59-0.91) for DOACs compared with warfarin during 3 years of follow-up. In the RISE-MS trial involving AF patients with mitral stenosis, there were no differences in ischemic stroke, systemic embolic events, or major bleeding between the rivaroxaban vs. warfarin groups during a 1-year follow-up as well as equal rate of increased thrombogenicity in the left atrial appendage at 6 months. The rate of silent cerebral ischemia at 12 months was higher in the warfarin group (17.6%) than that in the rivaroxaban group (13.3%). Conclusions: Current published studies supported DOACs' effectiveness in preventing thromboembolism in patients of AF with mitral or aortic stenosis. Further clinical trials could confirm these findings.
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Guo et al. (2022) conducted a systematic review in Atrial fibrillation with mitral or aortic stenosis (n=5,993). Direct oral anticoagulants vs. Warfarin was evaluated on Thromboembolism. Direct oral anticoagulants demonstrated effectiveness in preventing thromboembolism in patients with atrial fibrillation and mitral or aortic stenosis, though further large-scale randomized clinical trials are needed to confirm these findings.
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