Extracranial arterial and venous thromboembolism in patients with atrial fibrillation: A meta-analysis of randomized controlled trials

Kang-Ling Wang; Harry R Büller; Shinya Goto; Chun-Yi Lin; En-Yu Lai; Chun-Chih Chiu; Chern-En Chiang; Robert P Giugliano

doi:10.1016/j.hrthm.2016.12.038

Extracranial arterial and venous thromboembolism in patients with atrial fibrillation: A meta-analysis of randomized controlled trials

Heart Rhythm. 2017 Apr;14(4):599-605. doi: 10.1016/j.hrthm.2016.12.038. Epub 2017 Jan 4.

Authors

Kang-Ling Wang¹, Harry R Büller², Shinya Goto³, Chun-Yi Lin⁴, En-Yu Lai⁵, Chun-Chih Chiu⁶, Chern-En Chiang⁷, Robert P Giugliano⁸

Affiliations

¹ General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan. Electronic address: klwang2@vghtpe.gov.tw.
² Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.
³ Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan.
⁴ School of Nursing, National Yang-Ming University, Taipei, Taiwan.
⁵ Institute of Information Science, Academia Sinica, Taipei, Taiwan.
⁶ School of Medicine, National Yang-Ming University, Taipei, Taiwan.
⁷ General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan.
⁸ Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

PMID: 28062249
DOI: 10.1016/j.hrthm.2016.12.038

Abstract

Background: Thromboembolism prevention is central to atrial fibrillation (AF) management. Randomized controlled trials (RCTs) have primarily focused on stroke prevention. Detailed analyses of extracranial thromboembolic events, particularly in patients with low dose non-vitamin K antagonist oral anticoagulants (NOACs), are scarce.

Objective: The purpose of this study was to assess efficacy of NOACs in prevention of extracranial arterial and venous thromboembolism.

Methods: We searched PubMed, CENTRAL, and CINAHL through April 2016 for phase III RCTs of NOACs in patients with AF. Information regarding systemic embolism (SE), pulmonary embolism (PE), and deep vein thrombosis (DVT) was retrieved and compared by risk ratio (RR) and 95% confidence interval (CI) with a fixed-effects model. A network with additional RCTs involving antiplatelet agents was constructed. The surface under the cumulative ranking curve (SUCRA) of each treatment was calculated for assessing the best treatment in the network meta-analysis.

Results: Among 72,963 patients with AF from 5 RCTs, relative to warfarin, standard dose NOACs were associated with a lower risk of SE (RR 0.71, 95% CI 0.52-0.99) and similar risks of PE and DVT (RR 0.95, 95% CI 0.72-1.35; and RR 0.83, 95% CI 0.56-1.24, respectively). Compared with warfarin, risks of SE, PE, and DVT with low dose NOACs were similar. In network meta-analyses, standard dose NOACs were associated with the largest SUCRA for prevention of SE and PE.

Conclusion: In patients with AF, standard dose NOACs were the most efficacious treatment in preventing SE, whereas both dose regimens of NOACs were reasonable alternatives to warfarin in preventing venous thromboembolism.

Keywords: Anticoagulant; Atrial fibrillation; Cardiovascular outcomes; Systemic embolism; Venous thromboembolism.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't

MeSH terms

Anticoagulants* / classification
Anticoagulants* / pharmacology
Atrial Fibrillation* / complications
Atrial Fibrillation* / drug therapy
Humans
Pulmonary Embolism* / etiology
Pulmonary Embolism* / prevention & control
Randomized Controlled Trials as Topic
Risk Assessment
Treatment Outcome
Venous Thrombosis* / etiology
Venous Thrombosis* / prevention & control

Substances

Anticoagulants