What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Atrial fibrillation and cancer (n=229221). Intervention: Direct oral anticoagulants (DOACs) vs. Vitamin K antagonists (VKAs). Primary outcome: Systemic embolism or any stroke (RR 0.65, 95% CI 0.52-0.81, p=0.001).

October 12, 2020Open Access

Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and cancer a meta-analysis

Key Result

Direct oral anticoagulants reduced the risk of systemic embolism or any stroke (RR 0.65) and major bleeding (RR 0.68) compared to vitamin K antagonists in patients with atrial fibrillation and cancer.

Study Design

Type

Meta-Analysis (n=229,221)

Structured PICO

Do direct oral anticoagulants reduce thromboembolic events and bleeding compared to vitamin K antagonists in patients with non-valvular atrial fibrillation and cancer?

Population

9 studies pooling 229,221 patients with non-valvular atrial fibrillation and cancer (46,424 DOAC users and 182,797 VKA users)

Intervention

Direct oral anticoagulants (DOACs)

Comparator

Vitamin K antagonists (VKAs)

Outcome

Systemic embolism or any strokecomposite

In patients with non-valvular atrial fibrillation and cancer, DOACs are associated with significantly lower risks of thromboembolic events and major bleeding compared to VKAs.

Main Result

Effect estimate: RR 0.65 (95% CI 0.52-0.81)

p-value: p=0.001

Limitations

Only includes post-hoc analyses of RCTs or retrospective population-based cohorts
Some included studies reported unadjusted relative risks
Lack of information about type of cancer treatment and heterogeneity regarding the definition of active cancer
Lack of analysis on the basis of different cancer stages
Time-in-therapeutic range (TTR) for VKA was reported only in a few studies
Heterogeneous cancer population across included studies

Abstract

BACKGROUND: Direct oral anticoagulants (DOACs) are recommended as first-line anticoagulants in patients with atrial fibrillation (AF). However, in patients with cancer and AF the efficacy and safety of DOACs are not well established. OBJECTIVE: We performed a meta-analysis comparing available data regarding the efficacy and safety of DOACs vs vitamin K antagonists (VKAs) in cancer patients with non-valvular AF. METHODS: An online search of Pubmed and EMBASE libraries (from inception to May, 1 2020) was performed, in addition to manual screening. Nine studies were considered eligible for the meta-analysis involving 46,424 DOACs users and 182,797 VKA users. RESULTS: The use of DOACs was associated with reduced risks of systemic embolism or any stroke (RR 0.65; 95% CI 0.52-0.81; p 0.001), ischemic stroke (RR 0.84; 95% CI 0.74-0.95; p 0.007) and hemorrhagic stroke (RR 0.61; 95% CI 0.52-0.71; p 0.00001) as compared to VKA group. DOAC use was associated with significantly reduced risks of major bleeding (RR 0.68; 95% CI 0.50-0.92; p 0.01) and intracranial or gastrointestinal bleeding (RR 0.64; 95% CI 0.47-0.88; p 0.006). Compared to VKA, DOACs provided a non-statistically significant risk reduction of the outcomes major bleeding or non-major clinically relevant bleeding (RR 0.94; 95% CI 0.78-1.13; p 0.50) and any bleeding (RR 0.91; 95% CI 0.78-1.06; p 0.24). CONCLUSIONS: In comparison to VKA, DOACs were associated with a significant reduction of the rates of thromboembolic events and major bleeding complications in patients with AF and cancer. Further studies are needed to confirm our results.

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