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Published on: February 28, 2012
Direct Oral Anticoagulants versus Vitamin K Antagonists in Cirrhotic Patients with Atrial Fibrillation: Update of
Tong Hu1, Yi-Han Li1, Wen-Qiang Han1
1National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China.
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.
Insights
Direct oral anticoagulants (DOACs) show comparable efficacy to vitamin K antagonists (VKAs) for preventing stroke in atrial fibrillation (AF) patients with liver cirrhosis (LC). DOACs significantly reduce major bleeding risks, making them a potentially safer option.
Area of Science:
- Cardiology
- Hepatology
- Pharmacology
Background:
- Atrial fibrillation (AF) management necessitates effective ischemic stroke prevention.
- Direct oral anticoagulants (DOACs) offer an alternative to vitamin K antagonists (VKAs).
- Limited data exists on DOACs' efficacy and safety in AF patients with liver cirrhosis (LC).
Approach:
- A comprehensive meta-analysis was conducted, searching multiple databases up to February 2023.
- Seven clinical studies involving 7551 patients were analyzed.
- Statistical analysis was performed using Review Manager software version 5.3.
Key Points:
- DOACs demonstrated comparable efficacy to VKAs in reducing ischemic stroke/systemic thromboembolism.
- DOACs significantly lowered the risk of major bleeding, intracranial hemorrhage, and major gastrointestinal bleeding compared to VKAs.
- Subgroup analysis confirmed DOACs' reduced risk of major bleeding in advanced cirrhosis.
Conclusions:
- DOACs present a potentially safer oral anticoagulant option for AF patients with liver cirrhosis.
- DOACs are associated with more favorable safety profiles, particularly reduced bleeding risks.
- Further validation through randomized prospective studies is recommended.
