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Li D, Ma X, Zhou X, Qian Y. Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:755009. [PMID: 35222019 PMCID: PMC8880334 DOI: 10.3389/fphar.2022.755009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 01/12/2022] [Indexed: 12/11/2022] Open
Abstract
Objective: We aimed to compare non-vitamin K oral anticoagulants (NOACs) with a traditional antithrombotic such as vitamin K antagonist (VKA) and antiplatelet agents in patients after transcatheter aortic valve replacement (TAVR). Methods: We conducted a search in PubMed, EMBASE, and the Cochrane Library until November 2021 for studies involving comparisons of any type of NOACs, including dabigatran, apixaban, rivaroxaban, and edoxaban, with VKA or antiplatelet agents after TAVR. A comparison of NOACs versus VKA was performed in patients with an indication for oral anticoagulation. In addition, we compared NOACs versus antiplatelet in patients without such indication. We calculated the hazard ratios with 95% confidence intervals (CIs) to determine long-term outcomes. The primary outcome was a combined endpoint consisting of all-cause mortality, stroke, major bleeding, or any related clinical adverse events. Secondary outcomes were all-cause mortality, major bleeding, and stroke, respectively. Results: A total of 10 studies including 10,563 patients after TAVR were included in this meta-analysis. There were no significant differences in any of the long-term outcomes between the NOAC and VKA groups. Although there were no significant differences in the combined endpoint, major bleeding, or stroke, a significant difference was observed in the all-cause mortality (HR 1.74, 95% CI 1.25-2.43, p = 0.001) between the NOAC and antiplatelet groups. Conclusion: For patients with an indication for oral anticoagulation after TAVR, NOACs seem to be associated with noninferior outcomes compared with VKA therapy. However, for patients without an indication for oral anticoagulation, NOACs appear to be associated with a higher risk of all-cause death as compared with antiplatelet treatment. Systematic Review Registration: https://clinicaltrials.gov/, identifier CRD42020155122.
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Affiliation(s)
- Dongxu Li
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaofang Ma
- Department of Emergency Medicine, Emergency Medical Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Xu Zhou
- Evidence-based Medicine Research Center, Jiangxi University of Traditional Chinese Medicine, Nanchang, China
| | - Yongjun Qian
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
- National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
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Anticoagulants for stroke prevention in heart failure with reduced ejection fraction. Clin Res Cardiol 2021; 111:1-13. [PMID: 34448932 PMCID: PMC8766365 DOI: 10.1007/s00392-021-01930-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/17/2021] [Indexed: 11/08/2022]
Abstract
Impaired left-ventricular ejection-fraction (LV-EF) is a known risk factor for ischemic stroke and systemic embolism in patients with heart failure (HF) even in the absence of atrial fibrillation. While stroke risk is inversely correlated with LV-EF in HF patients with sinus rhythm, strategies using anticoagulation with Vitamin-K antagonists (VKA) were futile as the increase in major bleedings outweighed the potential benefit in stroke reduction. Non-Vitamin K oral anticoagulants (NOACs) proved to be an effective and in general safer approach for stroke prevention in patients with atrial fibrillation and may also have a favourable risk–benefit profile in HF patients. In HF patients with sinus rhythm, the COMPASS trial suggested a potential benefit for rivaroxaban, whereas the more dedicated COMMANDER-HF trial remained neutral on overall ischemic benefit owed to a higher mortality which was not influenced by anticoagulation. More recent data from subgroups in the COMMANDER-HF trial, however, suggest that there might be a benefit of rivaroxaban regarding stroke prevention under certain circumstances. In this article, we review the existing evidence for NOACs in HF patients with atrial fibrillation, elaborate the rationale for stroke prevention in HF patients with sinus rhythm, summarise the available data from anticoagulation trials in HF with sinus rhythm, and describe the patient who might eventually profit from an individualised strategy aiming to reduce stroke risk.
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Huang WY, Saver JL, Wu YL, Lin CJ, Lee M, Ovbiagele B. Major bleeding risk with non-vitamin K antagonist oral anticoagulant vs. aspirin in heart failure: network meta-analysis. ESC Heart Fail 2020; 7:3962-3970. [PMID: 32924283 PMCID: PMC7754774 DOI: 10.1002/ehf2.12994] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 06/30/2020] [Accepted: 08/17/2020] [Indexed: 11/10/2022] Open
Abstract
Aims Relative bleeding risks of different antithrombotic agents in heart failure (HF) patients is an important consideration in treatment decision making, making detailed comparative analysis desirable. The aim of this study was to conduct a network meta‐analysis to investigate the major bleeding risk for individual novel oral anticoagulants (NOACs) vs. aspirin among patients with HF. Methods and results We searched Pubmed, EMBASE, Cochrane Collaboration Central Register of Controlled Clinical Trials, and Clinicaltrials.gov from 1966 to November 2019 to identify relevant randomized clinical trials. Studies comparing individual NOACs vs. aspirin were analysed using direct study‐level meta‐analysis. Studies comparing aspirin to warfarin and NOACs to warfarin were then additionally added using network (direct and indirect) study‐level meta‐analysis. Primary endpoint was major bleeding. Final analysis included nine trials with 34 367 participants, including one direct comparison trial (apixaban vs. aspirin) and eight indirect comparison trials against the shared warfarin comparator (four aspirin trials and one trial each of apixaban, dabigatran, rivaroxaban, and edoxaban). For apixaban, network meta‐analysis combing direct and indirect comparison showed that major bleeding risk might not be different between apixaban and aspirin (odds ratio, 1.18 [95% confidence interval, 0.38 to 3.65]) in HF patients. In contrast, indirect‐comparison meta‐analysis showed dabigatran, rivaroxaban, and edoxaban compared with aspirin might be associated with a higher risk of major bleeding in HF patients. Conclusions In network meta‐analysis, apixaban might be associated with a comparable risk of major bleeding compared with aspirin in patients with HF, while other NOACs might be associated with a higher risk. However, such results were not strongly convincing because of lack of direct comparison in an original trial and small sample size of trials and participants. A clinical trial directly comparing apixaban vs. aspirin in patients with HF and sinus rhythm may be worth undertaking.
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Affiliation(s)
- Wen-Yi Huang
- Department of Neurology, College of Medicine, Chang Gung University, Chang Gung Memorial Hospital, Keelung Branch, No.222, Mai-Jin Road, Keelung, 204, Taiwan
| | - Jeffrey L Saver
- UCLA Stroke Center, University of California, 300 Medical Plaza Driveway B200, Los Angeles, CA, 90095, USA
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, No. 35, Keyan Road, Zhunan, Miaoli County, 350, Taiwan
| | - Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, National Yang-Ming University, No. 201, Sec. 2, Shipai Road, Beitou District Taipei, 112, Taiwan
| | - Meng Lee
- Department of Neurology, College of Medicine, Chang Gung University, Chang Gung Memorial Hospital, Chiayi Branch, 6 West Section, Chiapu Road, Puzi, 613, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, 505 Parnassus Ave, San Francisco, CA, 94143, USA
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