Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Bioprosthetic Valves—A Systematic Review and Meta-analysis

Oral anticoagulation is recommended for patients with atrial fibrillation and an elevated stroke risk. Direct oral anticoagulants (DOACs) are generally preferred over vitamin K antagonists. Nonetheless, there controversy persists regarding whether DOACs should be used in patients with atrial fibrillation and bioprosthetic valves. Therefore, we conducted this systematic review and meta-analysis to assess the safety and efficacy of DOACs compared to warfarin in this patient population. We performed a systematic search of the MEDLINE and PubMed Central databases for relevant articles. The incidence rate and risk ratio (RR) of all-cause mortality, cardiovascular mortality, ischemic stroke/systemic thromboembolism, hemorrhagic stroke/intracranial bleeding, major bleeding, and minor bleeding were calculated. A total of eight studies were included, including 5,300 patients (stratified as 1,638 patients in the DOAC arm and 3,662 patients in the warfarin arm). There was no significant difference in the rate of stroke/systemic thromboembolism [RR: 0.85; 95% confidence interval (CI): 0.43-1.69], all-cause mortality (RR: 0.77; 95% CI: 0.53-1.11), or cardiovascular death (RR: 0.81; 95% CI: 0.40-1.63) between DOACs and warfarin. Major bleeding and hemorrhagic stroke/intracranial bleeding were similar between both treatment arms (RR: 0.61; 95% CI: 0.35-1.06 and RR: 0.27; 95% CI: 0.06-1.13, respectively). In conclusion, DOACs are safe and effective in patients with atrial fibrillation and bioprosthetic valves. Future large-scale randomized studies are warranted to confirm this observation.