Direct oral anticoagulants in patients with atrial fibrillation and bioprosthetic valve replacement: A meta‐analysis

Abstract

Objectives This systematic review and meta‐analysis compares direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients with atrial fibrillation and bioprosthetic valve replacement or repair (BVR). Background The optimal anticoagulation therapy for patients with atrial fibrillation and a history of bioprosthetic valve replacement or repair (BVR) is not well understood. Methods We performed a systematic literature review to identify clinical studies that compared anticoagulation therapies for patients with atrial fibrillation and BVR. The primary outcomes of stroke, major bleeding, and mortality were reported as random effects risk ratio (RR) with 95% confidence interval. No prior ethical approval was required since all data is public. Results Our search yielded 101 potential studies. We included six studies reporting on 1911 patients. There was a lower risk of stroke and major bleeding in patients with atrial fibrillation after BVR treated with DOACs when compared to VKAs with risk ratios of 0.44 (95% CI 0.24–0.82, p < 0.01) and 0.53 (95% CI 0.34–0.83, p < 0.01), respectively. There was no statistically significant difference in mortality between patients with atrial fibrillation after BVR treated with DOACs compared to patients treated with VKAs with a risk ratio of 1.12 (95% CI 0.73–1.74, p = 0.60). Conclusion This systematic review and meta‐analysis suggests that DOACs are superior to VKAs with respect to stroke and major bleeding in patients with atrial fibrillation and BVR.

Optimal anticoagulation in patients with atrial fibrillation and bioprosthetic heart valves

“…Several studies suggest a preference for NOACs over VKAs among AF patients undergoing surgical BHV replacement [7,54,57,[63][64][65]; however, most of them [48,49,54,55,57,[62][63][64][65] included patients with concomitant antiplatelet therapy leading to several biases both for thromboembolic and bleeding outcomes. Three recent metanalyses [67][68][69] support the use of NOACs over VKAs in AF patients with BHVs, however, the large heterogeneity of the study populations (especially for age and comorbidities) and the inclusion of different valve surgeries make it difficult to generalize the results [67]. Few data support the early use of NOACs even in the first three months [14, ; however, the number of patients randomized in the first 3 months after the procedure is too small to draw definitive conclusions.…”

An Updated Meta-Analysis of DOACs vs. VKAs in Atrial Fibrillation Patients With Bioprosthetic Heart Valve

“…Recently, the effectiveness and safety of DOACs compared with VKAs in AF patients with BPHV have been explored in several studies (33)(34)(35)(36)(37) as shown in Supplementary Table 5. A prior systematic review by Kheiri et.…”

“…Cardoso et al also performed a meta-analysis by including 2 post-hoc analyses of RCTs and two RCTs, suggesting that DOACs were associated with a reduced incidence of SSE and major bleeding as compared with warfarin in AF patients with BPHV (34). In addition to RCTs, the meta-analyses by Adhikari et al, Lacy et al, and Yokoyama et al included a different number of observational studies (33,36,37). To our knowledge, this study is the largest to assess evidence in separate meta-analyses of RCTs (n = 4) and observational studies (n = 7) for DOACs compared with VKAs in AF patients with BPHV.…”