Direct Oral Anticoagulants versus Vitamin K Antagonists in Cirrhotic Patients with Atrial Fibrillation: Update of Systematic Review and Meta-Analysis

IF 2.8 4区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS American Journal of Cardiovascular Drugs Pub Date : 2023-08-28 DOI:10.1007/s40256-023-00598-1

Tong Hu, Yi-Han Li, Wen-Qiang Han, Kellina Maduray, Tong-Shuai Chen, Li Hao, Jing-Quan Zhong

{"title":"Direct Oral Anticoagulants versus Vitamin K Antagonists in Cirrhotic Patients with Atrial Fibrillation: Update of Systematic Review and Meta-Analysis","authors":"Tong Hu, Yi-Han Li, Wen-Qiang Han, Kellina Maduray, Tong-Shuai Chen, Li Hao, Jing-Quan Zhong","doi":"10.1007/s40256-023-00598-1","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><p>Prevention of ischemic stroke is an essential part of managing atrial fibrillation (AF). In recent years, direct oral anticoagulants (DOACs) have emerged as an alternative to vitamin K antagonists (VKAs). Little is understood regarding the efficacy and safety of DOACs in AF patients with liver cirrhosis (LC).</p><h3>Objective</h3><p>This meta-analysis is designed to evaluate the benefits and risks of DOACs compared to VKAs in AF patients with concomitant LC.</p><h3>Methods</h3><p>A thorough search was conducted in PubMed, Cochrane Library, Web of Science, Embase, Scopus, and CNKI databases up to February 2023. A total of seven clinical studies including 7551 patients were analyzed in this meta-analysis. All data analyses were performed using Review Manager software version 5.3.</p><h3>Results</h3><p>Regarding efficacy outcomes, DOACs had comparable clinical benefit in reducing ischemic stroke/systemic thromboembolism (HR=0.79, 95% CI [0.59, 1.06], <i>p</i> = 0.12) to VKAs. The incidence of all-cause death was similar between the DOACs and VKAs group (HR 0.94, 95% CI [0.69, 1.28], <i>p</i> = 0.69). Regarding safety outcomes, DOACs were associated with a significantly lower risk of major bleeding (HR 0.61, 95% CI [0.50, 0.75], <i>p</i> < 0.00001), intracranial hemorrhage (HR 0.55, 95% CI [0.31, 0.98], <i>p</i> = 0.04) and major gastrointestinal bleeding (HR 0.66, 95% CI [0.51, 0.85], <i>p</i> = 0.001) than VKAs. Additional subgroup analysis of advanced cirrhosis revealed that DOACs were associated with a significantly lower risk of major bleeding (HR 0.59, 95% CI [0.39, 0.89], <i>p</i> = 0.01) than VKAs. There were no significant differences between the DOACs and VKAs group concerning the incidence of ischemic stroke/systemic thromboembolism (HR 1.38, 95% CI [0.75, 2.55], <i>p</i> = 0.31) and major gastrointestinal bleeding (HR 0.65, 95% CI [0.41, 1.04], <i>p</i> = 0.08).</p><h3>Conclusion</h3><p>DOACs are associated with more favorable safety outcomes and may be a feasible option of oral anticoagulant for individuals with atrial fibrillation and cirrhosis. Pending validation by randomized prospective studies, the findings of this study should be interpreted with caution.</p></div>","PeriodicalId":7652,"journal":{"name":"American Journal of Cardiovascular Drugs","volume":"23 6","pages":"683 - 694"},"PeriodicalIF":2.8000,"publicationDate":"2023-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"American Journal of Cardiovascular Drugs","FirstCategoryId":"3","ListUrlMain":"https://link.springer.com/article/10.1007/s40256-023-00598-1","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"CARDIAC & CARDIOVASCULAR SYSTEMS","Score":null,"Total":0}

引用次数: 0

Abstract

Background

Prevention of ischemic stroke is an essential part of managing atrial fibrillation (AF). In recent years, direct oral anticoagulants (DOACs) have emerged as an alternative to vitamin K antagonists (VKAs). Little is understood regarding the efficacy and safety of DOACs in AF patients with liver cirrhosis (LC).

Objective

This meta-analysis is designed to evaluate the benefits and risks of DOACs compared to VKAs in AF patients with concomitant LC.

Methods

A thorough search was conducted in PubMed, Cochrane Library, Web of Science, Embase, Scopus, and CNKI databases up to February 2023. A total of seven clinical studies including 7551 patients were analyzed in this meta-analysis. All data analyses were performed using Review Manager software version 5.3.

Results

Regarding efficacy outcomes, DOACs had comparable clinical benefit in reducing ischemic stroke/systemic thromboembolism (HR=0.79, 95% CI [0.59, 1.06], p = 0.12) to VKAs. The incidence of all-cause death was similar between the DOACs and VKAs group (HR 0.94, 95% CI [0.69, 1.28], p = 0.69). Regarding safety outcomes, DOACs were associated with a significantly lower risk of major bleeding (HR 0.61, 95% CI [0.50, 0.75], p < 0.00001), intracranial hemorrhage (HR 0.55, 95% CI [0.31, 0.98], p = 0.04) and major gastrointestinal bleeding (HR 0.66, 95% CI [0.51, 0.85], p = 0.001) than VKAs. Additional subgroup analysis of advanced cirrhosis revealed that DOACs were associated with a significantly lower risk of major bleeding (HR 0.59, 95% CI [0.39, 0.89], p = 0.01) than VKAs. There were no significant differences between the DOACs and VKAs group concerning the incidence of ischemic stroke/systemic thromboembolism (HR 1.38, 95% CI [0.75, 2.55], p = 0.31) and major gastrointestinal bleeding (HR 0.65, 95% CI [0.41, 1.04], p = 0.08).

Conclusion

DOACs are associated with more favorable safety outcomes and may be a feasible option of oral anticoagulant for individuals with atrial fibrillation and cirrhosis. Pending validation by randomized prospective studies, the findings of this study should be interpreted with caution.

Abstract Image

查看原文

微信好友朋友圈 QQ好友复制链接

本刊更多论文

肝硬化心房颤动患者直接口服抗凝剂与维生素K拮抗剂的比较：系统综述和荟萃分析的更新。

背景：预防缺血性中风是治疗心房颤动（AF）的重要组成部分。近年来，直接口服抗凝剂（DOAC）已成为维生素K拮抗剂（VKAs）的替代品。关于DOACs治疗肝硬化房颤患者的疗效和安全性，人们知之甚少。目的：本荟萃分析旨在评估DOACs与VKAs相比在伴有LC的房颤患者中的益处和风险。方法：截至2023年2月，在PubMed、Cochrane Library、Web of Science、Embase、Scopus和CNKI数据库中进行了彻底搜索。本荟萃分析共分析了7项临床研究，包括7551名患者。所有数据分析均使用Review Manager软件5.3版进行。结果：就疗效结果而言，DOAC在减少缺血性卒中/系统性血栓栓塞方面具有与VKA相当的临床益处（HR=0.79，95%CI[0.59，1.06]，p=0.12）。DOACs组和VKAs组的全因死亡发生率相似（HR 0.94，95%CI[0.69，1.28]，p=0.69）。就安全性结果而言，DOACs与大出血风险显著降低相关（HR 0.61，95%CI[0.50，0.75]，p<0.00001），颅内出血（HR 0.55，95%CI[0.31，0.98]，p=0.04）和主要胃肠道出血（HR 0.66，95%CI[0.51，0.85]，p=0.001）。对晚期肝硬化的额外亚组分析显示，与VKAs相比，DOAC与大出血风险显著降低相关（HR 0.59，95%CI[0.39，0.89]，p=0.01）。DOACs组和VKAs组在缺血性卒中/系统性血栓栓塞的发生率（HR 1.38，95%CI[0.75，2.55]，p=0.31）和主要胃肠道出血的发病率（HR 0.65，95%CI[0.41，1.04]，p=0.08）方面没有显著差异心房颤动和肝硬化。在等待随机前瞻性研究的验证之前，应谨慎解释本研究的结果。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

求助全文

约1分钟内获得全文去求助

来源期刊

American Journal of Cardiovascular Drugs 医学-心血管系统

CiteScore

6.70

自引率

3.30%

发文量

审稿时长

>12 weeks

期刊介绍： Promoting rational therapy within the discipline of cardiology, the American Journal of Cardiovascular Drugs covers all aspects of the treatment of cardiovascular disorders, particularly the place in therapy of newer and established agents. Via a program of reviews and original clinical research articles, the journal addresses major issues relating to treatment of these disorders, including the pharmacology, efficacy and adverse effects of the major classes of drugs; information on newly developed drugs and drug classes; the therapeutic implications of latest research into the aetiology of cardiovascular disorders; and the practical management of specific clinical situations. The American Journal of Cardiovascular Drugs offers a range of additional enhanced features designed to increase the visibility, readership and educational value of the journal’s content. Each article is accompanied by a Key Points summary, giving a time-efficient overview of the content to a wide readership. Articles may be accompanied by plain language summaries to assist patients, caregivers and others in understanding important medical advances. The journal also provides the option to include various other types of enhanced features including slide sets, videos and animations. All enhanced features are peer reviewed to the same high standard as the article itself. Peer review is conducted using Editorial Manager®, supported by a database of international experts. This database is shared with other Adis journals.