Yi-Hsin Chan1,2,3, Hsin-Fu Lee1,2,4, Tze-Fan Chao5,6, Chia-Tung Wu1,2, Shang-Hung Chang1,2, Yung-Hsin Yeh1,2, Lai-Chu See7,8,9, Chi-Tai Kuo1,2, Pao-Hsien Chu1,2, Chun-Li Wang10,11, Gregory Y H Lip12. 1. The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan. 2. College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan. 3. Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan. 4. Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan. 5. Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. 6. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan. 7. Department of Public Health, College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan. 8. Biostatistics Core Laboratory, Molecular Medicine Research Center, Chang Gung University, Taoyuan, 33302, Taiwan. 9. Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, 33305, Taiwan. 10. The Cardiovascular Department, Chang Gung Memorial Hospital, No.259, Wenhua 1st Rd., Guishan Dist., Taoyuan City, 33302, Taiwan. wang3015@cgmh.org.tw. 11. College of Medicine, Chang Gung University, Taoyuan, 33302, Taiwan. wang3015@cgmh.org.tw. 12. Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK. gregory.lip@liverpool.ac.uk.
Abstract
BACKGROUND: Whether four direct oral anticoagulants (DOACs) are superior to warfarin among Asians with non-valvular atrial fibrillation (NVAF) remains unclear in the real-world setting. METHODS: We searched PubMed and Medline + Journals@Ovid + EMBASE from September 17, 2009 to May 4, 2019 to perform a systematic review and meta-analysis of all observational real-world studies comparing four DOACs with warfarin specifically focused on Asian patients with NVAF. RESULTS: From the original 212 results retrieved, 18 studies were included in the meta-analysis. Overall, DOACs were associated with lower risks of thromboembolism (hazard ratio; [95% confidence interval], 0.70; [0.63-0.78]), acute myocardial infarction (0.67; [0.57-0.79]), all-cause mortality (0.62; [0.56-0.69]), major bleeding (0.59; [0.50-0.69]), intracranial hemorrhage (0.50; [0.40-0.62]), gastrointestinal bleeding (0.66; [0.46-0.95]), and any bleeding (0.82; [0.73-0.92]) than warfarin. There was statistic heterogeneity between DOACs for the risks of thromboembolism (P interaction = 0.03) and acute myocardial infarction (P interaction = 0.007) when compared to warfarin. However, all DOACs showed lower risks of thromboembolism and acute myocardial infarction than warfarin when pooling studies that compared individual DOAC with warfarin. With regard to the other outcomes when compared to warfarin, there was no statistical heterogeneity between DOACs. In addition, the effectiveness and safety of four DOACs versus warfarin persisted in the subgroups of either standard-dose or low-dose DOACs. CONCLUSIONS: The meta-analysis shows that the DOACs had greater effectiveness and safety compared to warfarin in real-world practice for stroke prevention, among Asian patients with NVAF.
BACKGROUND: Whether four direct oral anticoagulants (DOACs) are superior to warfarin among Asians with non-valvular atrial fibrillation (NVAF) remains unclear in the real-world setting. METHODS: We searched PubMed and Medline + Journals@Ovid + EMBASE from September 17, 2009 to May 4, 2019 to perform a systematic review and meta-analysis of all observational real-world studies comparing four DOACs with warfarin specifically focused on Asian patients with NVAF. RESULTS: From the original 212 results retrieved, 18 studies were included in the meta-analysis. Overall, DOACs were associated with lower risks of thromboembolism (hazard ratio; [95% confidence interval], 0.70; [0.63-0.78]), acute myocardial infarction (0.67; [0.57-0.79]), all-cause mortality (0.62; [0.56-0.69]), major bleeding (0.59; [0.50-0.69]), intracranial hemorrhage (0.50; [0.40-0.62]), gastrointestinal bleeding (0.66; [0.46-0.95]), and any bleeding (0.82; [0.73-0.92]) than warfarin. There was statistic heterogeneity between DOACs for the risks of thromboembolism (P interaction = 0.03) and acute myocardial infarction (P interaction = 0.007) when compared to warfarin. However, all DOACs showed lower risks of thromboembolism and acute myocardial infarction than warfarin when pooling studies that compared individual DOAC with warfarin. With regard to the other outcomes when compared to warfarin, there was no statistical heterogeneity between DOACs. In addition, the effectiveness and safety of four DOACs versus warfarin persisted in the subgroups of either standard-dose or low-dose DOACs. CONCLUSIONS: The meta-analysis shows that the DOACs had greater effectiveness and safety compared to warfarin in real-world practice for stroke prevention, among Asian patients with NVAF.
Entities:
Keywords:
Atrial fibrillation; Direct thrombin inhibitor; Factor Xa inhibitor; Hemorrhage; Ischemic stroke; Mortality; Warfarin