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Doni K, Bühn S, Weise A, Mann NK, Hess S, Sönnichsen A, Salem S, Pieper D, Thürmann P, Mathes T. Safety outcomes of direct oral anticoagulants in older adults with atrial fibrillation: a systematic review and meta-analysis of (subgroup analyses from) randomized controlled trials. GeroScience 2024; 46:923-944. [PMID: 37261677 PMCID: PMC10828375 DOI: 10.1007/s11357-023-00825-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/10/2023] [Indexed: 06/02/2023] Open
Abstract
Balancing stroke prevention and risk of bleeding in patients with atrial fibrillation (AF) is challenging. Direct oral anticoagulants (DOACs) are by now considered standard of care for treating patients with AF in international guidelines. Our objective was to assess the safety of long-term intake of DOACs in older adults with AF. We included RCTs in elderly (≥ 65 years) patients with AF. A systematic search in MEDLINE and EMBASE was performed on 19 April 2022. For determination of risk of bias, the RoB 2 tool was applied. We pooled outcomes using random-effects meta-analyses. The quality of evidence was assessed using GRADE. Eleven RCTs with a total of 63,374 patients were identified. Two RCTs compared apixaban with either warfarin or aspirin, four edoxaban with either placebo, aspirin, or vitamin K antagonists (VKAs), two dabigatran with warfarin and three rivaroxaban with warfarin. DOACs probably reduce mortality in elderly patients with AF (HR 0.89 95%CI 0.77 to 1.02). Low-dose DOACs likely reduce bleeding compared to VKAs (HR ranged from 0.47 to 1.01). For high-dose DOACS the risk of bleeding varied widely (HR ranged from 0.80 to 1.40). We found that low-dose DOACs probably decrease mortality in AF patients. Moreover, apixaban and probably edoxaban are associated with fewer major or clinically relevant bleeding (MCRB) events compared to VKAs. For dabigatran and rivaroxaban, the risk of MCRB varies depending on dose. Moreover, subgroup analyses indicate that in the very old (≥ 85) the risk for MCRB events might be increased when using DOACs.Registration: PROSPERO: CRD42020187876.
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Affiliation(s)
- Katharina Doni
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
- Institute for Health Economics and Clinical Epidemiology of the University of Cologne, Gleueler Str. 176-178, 50935, Cologne, Germany
| | - Stefanie Bühn
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | - Alina Weise
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | - Nina-Kristin Mann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Simone Hess
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | | | - Susanna Salem
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | - Petra Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Tim Mathes
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany.
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany.
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany.
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