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Efficacy and safety of direct oral anticoagulants in morbidly obese patients with non-valvular atrial fibrillation: a systematic review and meta-analysis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Atrial fibrillation (AF) is the most common arrhythmia, with an estimated prevalence between 1–4%. On the other hand, obesity continued to be a prevalent health issue worldwide. Direct oral anticoagulants (DOACs) have been increasingly preferred over warfarin; however, The International Society of Thrombosis and Hemostasis (ISTH) recommended avoiding the use of DOACs in patients with a BMI >40 or weight >120 kg because of limited clinical data in these patients. In this meta-analysis, we aimed to evaluate the efficacy and safety of DOACs in morbidly obese patients with non-valvular AF.
Method
We performed a comprehensive literature search using multiple databases from database inception through January 2021, for all the studies that evaluated the efficacy and safety of DOACs in morbidly obese patients with non-valvular AF. The primary outcome of interest was stroke or systemic embolism (SSE) rate. The secondary outcome was major bleeding (MB). All meta-analyses were conducted using a random-effect model.
Results
A total of 10 studies including 89,494 morbidly obese patients (BMI >40 or weight >120 kg) with non-valvular AF on oral anticoagulation therapy (45427 on DOACs vs. 44067 on warfarin) were included in the final analysis. One included study was a randomized controlled trial (RCT), another study was a post hoc analysis of an RCT and the rest were retrospective cohort studies. The mean follow-up period was 1.8 years (range 8 months to 3.1 years). The SSE rate was significantly lower in DOACs group compared to warfarin group (odds ratio (OR): 0.71; 95% confidence interval (CI): 0.62, 0.81; p<0.0001; I2=0%). MB rate was also significantly lower in DOACs group compared to the warfarin group (OR 0.60, 95% CI 0.46–0.78, P<0.0001, I2=86%). Subgroup analysis in the rivaroxaban and apixaban AF cohort showed a statistically significant difference in SSE and MB event rates favoring both over warfarin therapy. Dabigatran showed non-inferiority to warfarin in SSE rate but superiority in the safety outcome.
Conclusions
Our meta-analysis demonstrated that DOACs are effective and safe when compared to warfarin in morbidly obese patients. However, more large scale randomized clinical trials are needed to further evaluate the efficacy and safety of DOACs compared to warfarin in this cohort of patients.
Funding Acknowledgement
Type of funding sources: None. Stroke and systemic embolism eventsMajor bleeding events
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Distal versus conventional transradial access for coronary angiography and intervention: a systematic review and meta-analysis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Distal transradial artery access (DTRA) has recently gained attention due to potential benefits in terms of local complications and risk of superficial palmar arch ischemia in case of radial artery occlusion.
Purpose
In this meta-analysis, we aimed to evaluate the utility of DTRA compared to conventional transradial artery access (CTRA) for coronary angiography and intervention.
Method
We performed a comprehensive literature search using multiple databases from inception through February 2021 for all the studies that evaluated the efficacy and safety of DTRA for coronary angiography and intervention. The primary outcome of interest was access success rate. The secondary outcomes were periprocedural local complications (site hematoma, radial artery occlusion or spasm) and procedural characteristics (cannulation, fluoroscopy, and radial artery compression times). All meta-analyses were conducted using a random-effect model.
Results
A total of 8 studies including 1630 patients (805 underwent DTRA vs. 825 with CTRA), were included in the final analysis. Three of the included studies were randomized controlled trials (RCTs), and the remainder were observational studies. The access success rate was similar in the two groups (odds ratio (OR): 0.61; 95% confidence interval (CI): 0.18–2.09; P=0.43; I2=72%). Similarly, no difference was observed in the overall periprocedural local complications rate (OR 0.63, 95% CI 0.38–1.04, P=0.07, I2=25%). On subgroup analysis, the rate of radial artery occlusion was significantly lower in DRTA group (OR 0.33, 95% CI 0.13–0.82, P=0.02, I2=0%). Regarding the procedural characteristics, the two approaches were different only in the cannulation time favoring the CTRA group (mean difference in minutes [MD] 0.96, 95% CI 0.16–1.76; P=0.02).
Conclusions
The DTRA represents an alternative site for radial artery access for coronary angiography and interventions, with a high success rate accompanied by a low risk of complications. Although the cannulation time was longer for the DTRA, this can potentially improve with training, practice, and utilization of ultrasound-guided punctures. The major advantage provided by the DTRA is the trend toward a lower risk of radial artery occlusion, which is frequently observed with the conventional approach. Further adequately powered RCTs are needed to confirm the safety and efficacy of this approach.
Funding Acknowledgement
Type of funding sources: None. Central illustration
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