August 19, 2019Open Access

Non–Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Asians With Atrial Fibrillation

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Atrial fibrillation. Intervention: Non-vitamin K antagonist oral anticoagulants (NOACs) vs. Warfarin. Primary outcome: Stroke or systemic embolism (RCTs) (RR 0.73, 95% CI 0.59-0.90).

Key Result

In Asian patients with atrial fibrillation, NOACs significantly reduced the risk of stroke or systemic embolism compared to warfarin in both randomized trials (RR 0.73) and real-world studies (RR 0.75).

Study Design

Type

Meta-Analysis

Structured PICO

Do NOACs reduce stroke, systemic embolism, and bleeding compared to warfarin in Asian patients with atrial fibrillation?

Population

Asian patients with atrial fibrillation (pooled from 5 NOAC trials and 21 observational cohorts)

Intervention

Non-vitamin K antagonist oral anticoagulants (NOACs)

Comparator

Warfarin

Outcome

Stroke or systemic embolismhard clinical

NOACs are effective and safe alternatives to warfarin for stroke prevention in Asian patients with atrial fibrillation, demonstrating reduced risks of stroke, mortality, and bleeding.

Main Result

Effect estimate: RR 0.73 (95% CI 0.59-0.90)

Limitations

Heterogeneous population across included studies might result in uncontrolled confounding
Residual confounders might exist due to the nature of real-world data
Most of the included observational cohorts were retrospective
Subgroup analysis based on time within therapeutic range of warfarin users was not performed due to limited data
Small number of included studies in some subgroups limited the validity of corresponding findings

Abstract

Background and Purpose- Several randomized trials and real-world studies have reported the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in Asian patients with atrial fibrillation; and therefore, this meta-analysis was aimed to compare the effects of NOACs with warfarin for atrial fibrillation stroke prevention in Asians. Methods- The PubMed and Embase databases were searched from January 2009 to February 2019 for studies on comparisons of NOACs versus warfarin in Asians. Risk ratios (RRs) with 95% CIs were pooled using a random-effects model. Results- Five NOAC trials and 21 observational cohorts were included. For the NOAC trials, compared with warfarin, NOACs was associated with reduced risks of stroke or systemic embolism (RR, 0.73; 95% CI, 0.59-0.90), all-cause death (RR, 0.83; 95% CI, 0.73-0.95), major bleeding (RR, 0.59; 95% CI, 0.48-0.72), and intracranial bleeding (RR, 0.36; 95% CI, 0.26-0.49). For the real-world data, compared with warfarin, NOACs was associated with decreased rates of stroke or systemic embolism (RR, 0.75; 95% CI, 0.68-0.82), ischemic stroke (RR, 0.70; 95% CI, 0.59-0.83), myocardial infarction (RR, 0.74; 95% CI, 0.58-0.93), all-cause death (RR, 0.67; 95% CI, 0.59-0.77), major bleeding (RR, 0.63; 95% CI, 0.55-0.73), intracranial bleeding (RR, 0.50; 95% CI, 0.43-0.59), and gastrointestinal bleeding (RR, 0.65; 95% CI, 0.51-0.84). The results did not change in the subgroup analyses based on the type and dose of NOACs. Conclusions- Based on published NOAC trials and real-world studies, the use of NOACs is noninferior to warfarin in Asians with atrial fibrillation irrespective of the NOAC type and dose.

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