Effectiveness and Safety of Intracranial Events associated with the use of Direct Oral Anticoagulants for Atrial Fibrillation: A Systematic Review and Meta-analysis of 92 Studies

AIM

Observational studies have investigated the effectiveness and safety of Direct Oral Anticoagulants (DOACs) and Vitamin K antagonists (VKA) used in Non-Valvular Atrial Fibrillation. We performed a systematic review and meta-analysis assessing the risk of ischemic stroke, Thromboembolism (TE) and Intracranial Hemorrhage (ICH) associated with the use of DOACs and VKA.

METHODS

Medline and Embase were systematically searched until April 2021. Observational studies were gathered and hazard ratios (HRs) with 95% confidence intervals (CI) were extracted. Subgroup analyses based on DOAC doses, history of chronic kidney disease, stroke, exposure to VKA, age, and gender were performed. A random-effects model was used.

RESULTS

We included 92 studies and performed 107 comparisons. Apixaban was associated with lower risk of stroke [HR: 0.82, 95% CI: 0.68-0.99] compared to Dabigatran. Rivaroxaban was associated with lower risk of stroke [HR: 0.90, 95% CI: 0.83-0.98] compared to VKA. Dabigatran [HR: 0.85, 95% CI: 0.80-0.91], Rivaroxaban [HR: 0.83, 95% CI: 0.77-0.89] and Apixaban [HR: 0.75, 95% CI: 0.65-0.86] were associated with lower risk for TE/stroke compared to VKA. Apixaban [HR: 1.32, 95% CI: 1.03-1.68] and Rivaroxaban [HR: 1.58, 95% CI: 1.31-1.89] were associated with higher risk of ICH compared to Dabigatran. Dabigatran [HR: 0.48, 95% CI: 0.44-0.52], Apixaban [HR: 0.60, 95% CI: 0.49-0.73] and Rivaroxaban [HR: 0.73, 95% CI: 0.65-0.81] were associated with lower risk of ICH compared to VKA.

CONCLUSIONS

Our study demonstrated significant differences in the risk of ischemic stroke, TE/stroke, and ICH associated with individual DOACs compared to both other DOACs and VKA.