Comparing clinical outcomes of NOACs with warfarin on atrial fibrillation with Valvular heart diseases: a meta-analysis

Qiyu He; Chun-Yat Sze; Tin-Yau Shum; Guang Hao; Nga-Yin Belinda Wong; Tat‐Hang Sin; Wei Wei; Sujian Xia

doi:10.1186/s12872-019-1089-0

May 15, 2019BMC Cardiovascular DisordersOpen Access

Comparing clinical outcomes of NOACs with warfarin on atrial fibrillation with Valvular heart diseases: a meta-analysis

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Why the study?

Warfarin is the standard of care for atrial fibrillation, but the efficacy of novel oral anticoagulants in valvular atrial fibrillation remains unclear.

Do NOACs reduce stroke, systemic embolic events, major bleeding, and all-cause mortality compared to warfarin in patients with atrial fibrillation and valvular heart diseases?

Key Points

To compare the efficacy and safety outcomes of novel oral anticoagulants (NOACs) versus warfarin in patients with atrial fibrillation and valvular heart disease.
Searched Embase, Cochrane, and PubMed databases, screening 496 articles and including 6 studies in the meta-analysis.
Used a random-effects model to assess pooled relative risks (RR) with 95% confidence intervals (CI) for stroke, systemic embolic events, major bleeding, and all-cause mortality.
NOACs demonstrated a statistically significant reduction in stroke and systemic embolic events compared to warfarin (RR: 0.66, 95% CI: 0.46 to 0.95).
No statistically significant differences were observed between NOACs and warfarin for major bleeding (RR: 0.714, 95% CI: 0.46 to 1.11) or all-cause mortality (RR: 0.84, 95% CI: 0.58 to 1.21).

Structured PICO

Do NOACs reduce stroke, systemic embolic events, major bleeding, and all-cause mortality compared to warfarin in patients with atrial fibrillation and valvular heart diseases?

P

Population

Patients with atrial fibrillation and valvular heart diseases (meta-analysis of 6 articles)

I

Intervention

Novel oral anticoagulants (NOACs)

C

Comparator

Warfarin

O

Outcome

Stroke and systemic embolic event (SSEE)hard clinical

In patients with atrial fibrillation and valvular heart disease, NOACs are significantly more protective against embolic events compared to warfarin, without increasing the risk of major bleeding or all-cause mortality.

Implication

Supports NOAC preference over warfarin in AF with valvular heart disease; extends evidence to this population.

Abstract

Warfarin is the standard of care and NOAC (Novel oral anticoagulants) are a group of newer drugs for such purposes. NOAC has a generally better profile (Clear interaction, less side effect, require less monitoring). However, its efficacy on valvular atrial fibrillation remains unclear. We researched literature articles from Embase, Cochrane and PubMed. Then we meta-analysed these six articles to assess pooled estimate of relative risk (RR) and 95% confidence intervals (Cl) using random-effects model for stroke, systemic embolic event, major bleeding and all-cause mortality. Heterogeneity across study was tested with Cochran’s Q Test and I 2 Test. The bias of studies was first tested by examining the symmetry of Funnel Plot. Cochrane’s Collaboration Tool was also used to report any presented bias. We collected 496 articles in total and finally we included six articles in our meta-analysis. For SSEE (Stroke, Systemic Embolic Event), the pooled relative risk showed a significantly better clinical outcome of NOAC (RR: 0.66; 95% CI: 0.46 to 0.95). However, there is no significant difference in major bleeding (RR: 0.714, 95% CI:0.46 to 1.11) and all-cause mortality (RR: 0.84, 95% CI: 0.58 to 1.21). Compared to Warfarin, NOAC is significantly more protective against the embolic event, but no significant difference in lowering risk of major bleeding, all-cause mortality or all aspects of post-TAVI (Trans-catheter aortic valve implantation).