Bleeding of New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Meta-Analysis of Randomized Controll
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ORIGINAL ARTICLE
Bleeding of New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials Joey S. W. Kwong & Yat-Yin Lam & Bryan P. Yan & Cheuk-Man Yu
Published online: 8 December 2012 # Springer Science+Business Media New York 2012
Abstract Purpose Oral direct factor Xa inhibitors and oral direct thrombin inhibitors are new oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF). We systematically reviewed their risk of major bleeding and efficacy in thromboembolism reduction in AF. Methods Eligible randomized controlled trials evaluating NOACs for stroke prevention in AF patients were identified from a systematic search of MEDLINE, EMBASE and the Cochrane database. Risk ratios (RRs) and 95 % confidence intervals (CIs) were calculated using a Mantel-Haenzel random-effects model. Results A total of 13 studies (n061,406) were included. Oral direct factor Xa inhibitors were more effective in reducing stroke and systemic embolism compared to controls (RR 0.71, 95 % CI 0.54–0.92, P00.009) or vitamin K antagonists (VKAs) (RR 0.84, 95 % CI 0.74–0.94, P00.002), with no significant difference in major and clinically relevant nonmajor (CRNM) bleeding (against controls: RR 0.94, 95 % CI 0.75–1.18, P00.60; against VKAs: RR 0.90, 95 % 0.69– 1.17, P00.44). Oral direct thrombin inhibitors were associated with an improved major and CRNM bleeding profile (both comparisons: RR 0.88, 95 % CI 0.78–0.98, P00.02) and a significant reduction in stroke and systemic embolism (against controls: RR 0.79, 95 % CI 0.66–0.93, P00.006; against VKAs: RR 0.78, 95 % CI 0.66–0.93, P00.006). Conclusions Oral direct factor Xa inhibitors and oral direct thrombin inhibitors are more effective in reducing stroke J. S. W. Kwong : Y.-Y. Lam : B. P. Yan : C.-M. Yu (*) Institute of Vascular Medicine, Li Ka Shing Institute of Health Sciences, S.H. Ho Cardiovascular Disease and Stroke Centre, Heart Education And Research Training (HEART) Centre and Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong, SAR, China e-mail: [email protected]
and systemic embolism without increasing the risk of major bleeding compared to traditional oral anticoagulants. This favorable risk-benefit balance should be further confirmed by long-term, large-scale safety studies. Keywords Anticoagulants . Atrial fibrillation . Hemorrhage . Meta-analysis . Stroke
Introduction Atrial fibrillation (AF) is a common arrhythmia and an estimated 2.2 million people in America and 4.5 million in the European Union have AF [1]. Prevalence is age-dependent, with a lower prevalence in those aged below 60 and increases to 8 % in those aged 80 and above [1]. AF is an independent risk factor for stroke and increases the risk by up to 5-fold; AFrelated strokes are associated with high mortality and morbidity compared to non-AF strokes [2]. Oral anticoagulants are the treatment of choice for long-term stroke prevention in AF a
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