Key result
In patients with concomitant atrial fibrillation and chronic kidney disease, DOACs were associated with significantly reduced bleeding compared to warfarin in non-RCTs (OR 0.65).
Why the study?
The safety and efficacy of DOACs compared with warfarin needed evaluation in AF patients with CKD or valvular disease, populations typically excluded from large trials.
Does DOAC therapy reduce bleeding and thromboembolic events compared to warfarin in patients with atrial fibrillation and concomitant chronic kidney disease or valvular disease?
Meta-Analysis (n=310,478)
Does DOAC therapy reduce bleeding and thromboembolic events compared to warfarin in patients with atrial fibrillation and concomitant chronic kidney disease or valvular disease?
Odds Ratio: 0.65 (95% CI 0.49–0.86)
p-value: p=0.003
DOACs appear to be a safe and effective alternative to warfarin in patients with atrial fibrillation and concomitant chronic kidney disease or non-mechanical valvular heart disease, potentially offering lower risks of bleeding and stroke.
Supports DOAC use over warfarin to reduce bleeding in AF with CKD; leaves open RCT confirmation.
Objective To analyze the safety and efficacy of different direct oral anticoagulant agents (DOACs) compared to warfarin in patients with concomitant atrial fibrillation (AF) and valvular disease or concomitant AF and chronic kidney disease (CKD). Methods We conducted literature searches in MEDLINE, Embase, and EBM Reviews to examine randomized-controlled trials (RCTs) and non-RCTs that included the aforementioned patient populations treated with warfarin or DOAC (rivaroxaban, dabigatran, apixaban, or edoxaban) and assessed outcomes of bleeding, stroke, or systemic/arterial thromboembolism. Meta-analysis was performed for eligible studies using the Mantel-Haenszel method random-effects model. Results 3,172 studies were screened and 154 studies were selected after two levels of screening. Meta-analysis showed that, in patients with concomitant AF and CKD, DOAC was associated with reduced bleeding in non-RCTs (OR 0.65, 95% Cl [0.49, 0.86], p=0.003), particularly in more severe CKD (eGFR < 60mL/min/1.73m 2 ). Apixaban in particular was associated with reduced bleeding (OR 0.52, 95% Cl [0.44, 0.63], p<0.00001) and stroke incidence (OR 0.60, 95% Cl [0.41, 0.87], p=0.007). In patients with concomitant AF and valvular disease, DOAC was associated with reduced bleeding (OR 0.75, 95% CI [0.57, 0.97], p=0.03) and stroke incidence (OR 0.66, 95% CI [0.47, 0.93], p=0.02) in non-RCTs. Conclusion Our study studied populations that are typically excluded from large-scale anticoagulation studies and our findings suggest that DOACs may be superior to warfarin both in the prevention of thromboembolic event and in the reduction of bleeding risks in patients with concomitant CKD or valvular disease.
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Liang et al. (2024) conducted a meta-analysis in Atrial fibrillation with concomitant chronic kidney disease or valvular disease (n=310,478). DOACs (rivaroxaban, dabigatran, apixaban, edoxaban) vs. Warfarin was evaluated on Bleeding events in patients with concomitant AF and CKD (non-RCTs) (OR 0.65, 95% CI 0.49, 0.86, p=0.003). In patients with concomitant atrial fibrillation and chronic kidney disease, DOACs were associated with significantly reduced bleeding compared to warfarin in non-RCTs (OR 0.65).
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