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      Call for Papers: Sex and Gender in Neurodegenerative Diseases

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      About Neurodegenerative Diseases: 1.9 Impact Factor I 5.9 CiteScore I 0.648 Scimago Journal & Country Rank (SJR)

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      Effectiveness and Safety of Non-Vitamin K Oral Anticoagulants versus Warfarin in Patients with Atrial Fibrillation and Previous Stroke: A Systematic Review and Meta-Analysis

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          Abstract

          Introduction

          Current evidence regarding the clinical outcomes of non-vitamin K oral anticoagulants (NOACs) versus warfarin in patients with atrial fibrillation (AF) and previous stroke is inconclusive, especially in patients with previous intracranial haemorrhage (ICrH). We aim to undertake a systematic review and meta-analysis assessing the effectiveness and safety of NOACs versus warfarin in AF patients with a history of stroke.

          Methods

          We searched studies published up to December 10, 2022, on PubMed, Medline, Embase, and Cochrane Central Register of Controlled Trials. Studies on adults with AF and previous ischaemic stroke (IS) or IrCH receiving either NOACs or warfarin and capturing outcome events (thromboembolic events, ICrH, and all-cause mortality) were eligible for inclusion.

          Results

          Six randomized controlled trials (RCTs) (including 19,489 patients with previous IS) and fifteen observational studies (including 132,575 patients with previous IS and 13,068 patients with previous ICrH) were included. RCT data showed that compared with warfarin, NOACs were associated with a significant reduction in thromboembolic events (odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.75–0.96), ICrH (OR: 0.57, 95% CI: 0.36–0.90), and all-cause mortality (OR: 0.88, 95% CI: 0.80–0.98). In analysing observational studies, similar results were retrieved. Moreover, patients with previous ICrH had a lower OR on thromboembolic events than those with IS (OR: 0.66, 95% CI: 0.46–0.95 vs. OR: 0.80, 95% CI: 0.70–0.93) in the comparison between NOACs and warfarin.

          Conclusions

          Observational data showed that in AF patients with previous stroke, NOACs showed better clinical performance compared to warfarin and the benefits of NOACs were more pronounced in patients with previous IrCH versus those with IS. RCT data also showed NOACs are superior to warfarin. However, current RCTs only included AF patients who survived an IS, and further large RCTs focused on patients with previous ICrH are warranted.

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            Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.

            Christian Ruff, Robert Giugliano, Eugene Braunwald … (2014)
            Four new oral anticoagulants compare favourably with warfarin for stroke prevention in patients with atrial fibrillation; however, the balance between efficacy and safety in subgroups needs better definition. We aimed to assess the relative benefit of new oral anticoagulants in key subgroups, and the effects on important secondary outcomes. We searched Medline from Jan 1, 2009, to Nov 19, 2013, limiting searches to phase 3, randomised trials of patients with atrial fibrillation who were randomised to receive new oral anticoagulants or warfarin, and trials in which both efficacy and safety outcomes were reported. We did a prespecified meta-analysis of all 71,683 participants included in the RE-LY, ROCKET AF, ARISTOTLE, and ENGAGE AF-TIMI 48 trials. The main outcomes were stroke and systemic embolic events, ischaemic stroke, haemorrhagic stroke, all-cause mortality, myocardial infarction, major bleeding, intracranial haemorrhage, and gastrointestinal bleeding. We calculated relative risks (RRs) and 95% CIs for each outcome. We did subgroup analyses to assess whether differences in patient and trial characteristics affected outcomes. We used a random-effects model to compare pooled outcomes and tested for heterogeneity. 42,411 participants received a new oral anticoagulant and 29,272 participants received warfarin. New oral anticoagulants significantly reduced stroke or systemic embolic events by 19% compared with warfarin (RR 0·81, 95% CI 0·73-0·91; p<0·0001), mainly driven by a reduction in haemorrhagic stroke (0·49, 0·38-0·64; p<0·0001). New oral anticoagulants also significantly reduced all-cause mortality (0·90, 0·85-0·95; p=0·0003) and intracranial haemorrhage (0·48, 0·39-0·59; p<0·0001), but increased gastrointestinal bleeding (1·25, 1·01-1·55; p=0·04). We noted no heterogeneity for stroke or systemic embolic events in important subgroups, but there was a greater relative reduction in major bleeding with new oral anticoagulants when the centre-based time in therapeutic range was less than 66% than when it was 66% or more (0·69, 0·59-0·81 vs 0·93, 0·76-1·13; p for interaction 0·022). Low-dose new oral anticoagulant regimens showed similar overall reductions in stroke or systemic embolic events to warfarin (1·03, 0·84-1·27; p=0·74), and a more favourable bleeding profile (0·65, 0·43-1·00; p=0·05), but significantly more ischaemic strokes (1·28, 1·02-1·60; p=0·045). This meta-analysis is the first to include data for all four new oral anticoagulants studied in the pivotal phase 3 clinical trials for stroke prevention or systemic embolic events in patients with atrial fibrillation. New oral anticoagulants had a favourable risk-benefit profile, with significant reductions in stroke, intracranial haemorrhage, and mortality, and with similar major bleeding as for warfarin, but increased gastrointestinal bleeding. The relative efficacy and safety of new oral anticoagulants was consistent across a wide range of patients. Our findings offer clinicians a more comprehensive picture of the new oral anticoagulants as a therapeutic option to reduce the risk of stroke in this patient population. None. Copyright © 2014 Elsevier Ltd. All rights reserved.
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              2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation

              Craig T. January, L Wann, Hugh Calkins … (2019)
              Article 0 comments Cited 807 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Neuroepidemiology
                Journal ID (iso-abbrev): Neuroepidemiology
                Journal ID (hwp): NED
                Journal ID (publisher-id): NED
                Title: Neuroepidemiology
                Publisher: S. Karger AG (Basel, Switzerland )
                ISSN (Print): 0251-5350
                ISSN (Electronic): 1423-0208
                Publication date (Electronic): 17 October 2023
                Publication date (Print): February 2024
                Volume: 58
                Issue: 1
                Pages: 1-14
                Affiliations
                [1]School of Life Course and Population Sciences, King’s College London, London, UK
                Author notes
                Correspondence to: Minglei Shi, minglei.shi@ 123456kcl.ac.uk

                Minglei Shi and Lu Liu contributed equally to this work.

                Minglei Shi and Lu Liu are joint first authors.

                Vasa Curcin and Yanzhong Wang contributed equally to this work.

                Vasa Curcin and Yanzhong Wang are joint senior authors.

                Article
                Publisher ID: 534596
                DOI: 10.1159/000534596
                PMC ID: 10836928
                PubMed ID: 37848006
                SO-VID: 1ede3be7-abfd-44c6-8873-757d1ecea4cf
                Copyright © © 2023 The Author(s). Published by S. Karger AG, Basel
                License:

                This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC) ( http://www.karger.com/Services/OpenAccessLicense). Usage and distribution for commercial purposes requires written permission.

                History
                Date received : 24 June 2023
                Date accepted : 10 October 2023
                Date: 2024
                Page count
                Figures: 6, References: 42, Pages: 14
                Funding
                H.W. and Y.W. received funding from the European Union’s Horizon 2020 research and innovation programme under Grant agreement No. 754517. L.L. received financial support from the China Scholarship Council PhD Scholarship (CSC No. 202108310074). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Systematic Review

                ScienceOpen disciplines: Neurosciences
                Keywords: stroke,atrial fibrillation,non-vitamin k oral anticoagulants,warfarin,anticoagulation
                Data availability:
                ScienceOpen disciplines: Neurosciences
                Keywords: stroke, atrial fibrillation, non-vitamin k oral anticoagulants, warfarin, anticoagulation

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