Effect of Oral Anticoagulants in Atrial Fibrillation Patients with Polypharmacy: A Meta-analysis

Abstract

Background The aim of the present meta-analysis was to evaluate the effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) in atrial fibrillation (AF) patients with polypharmacy. Methods and Results Randomized controlled trials or observational studies reporting the data of NOACs versus VKAs among AF patients with polypharmacy were included. The search was performed in the PubMed and Embase databases up to November 2022. A total of 12 studies involving 767,544 AF patients were included. For the primary outcomes, the use of NOACs compared with VKAs was significantly associated with a reduced risk of stroke or systemic embolism in AF patients with moderate polypharmacy (hazard ratio [HR]: 0.77 [95% confidence interval [CI]: 0.69–0.86]) and severe polypharmacy (HR: 0.76 [95% CI: 0.69–0.82]), but there was no significant difference in major bleeding (moderate polypharmacy: HR: 0.87 [95% CI: 0.74–1.01]; severe polypharmacy: HR: 0.91 [95% CI: 0.79–1.06]) between the two groups. In secondary outcomes, there were no differences in the rates of ischemic stroke, all-cause death, and gastrointestinal bleeding between the NOAC- and VKA- users, but NOAC users had a reduced risk of any bleeding compared with VKA- users. Compared with VKAs, the risk of intracranial hemorrhage was reduced in NOAC- users with moderate polypharmacy but not severe polypharmacy. Conclusion In patients with AF and polypharmacy, NOACs showed advantages over VKAs in stroke or systemic embolism and any bleeding, and were comparable to VKAs for major bleeding, ischemic stroke, all-cause death, intracranial hemorrhage, and gastrointestinal bleeding.

NOACs in Atrial Fibrillation Patients with Polypharmacy

“…Conversely, the paper by Grymonprez et al 15 extends previous real-word data on the effectiveness and safety of NOACs over vitamin K antagonists (VKAs), as shown in a recent meta-analysis of patients with AF treated with polypharmacy, 18 by confirming an overall better safety profile on NOACs in polymedicated patients. While no differences appear in terms of ischemic events, apixaban showed a significantly better safety profile, with lower risk of both major and gastrointestinal bleeding compared with other NOACs, confirming previous evidence reported in high-risk patients such as frail ones.…”

Atrial fibrillation: comorbidities, lifestyle, and patient factors

“… 266 , 267 , 271 In a meta-analysis of RCTs and observational studies (12 studies, 767,544 patients) NOACs compared with VKAs reduced risk of stroke or systemic embolism in AF patients with moderate polypharmacy (HR 0.77, 95% CI 0.69–0.86) and severe polypharmacy (HR 0.76, 95% CI 0.69–0.82), without affecting the risk of bleeding. 272 In contrast, warfarin use posed excess risk of adverse events in polypharmacy. These data indicate that polypharmacy itself should not be a barrier for NOAC use but requires careful and holistic approach for prescribing (ABC pathway).…”

Racial Differences in Bleeding Risk: An Ecological Epidemiological Study Comparing Korea and United Kingdom Subjects

“…Conducting health check-ups across the general population, including high-risk cohorts, would enable a more effective allocation of medical resources. [38][39][40] It would also facilitate holistic approaches that reflect the characteristics of different populations, as recommended in guidelines, and ultimately lead to better outcomes. 41,42 Limitations Some limitations still exist in our study.…”