NOACs versus warfarin for stroke prevention in patients with AF: a systematic review and meta-analysis

Tim Hicks; Fiona Stewart; Anne Eisinga

doi:10.1136/openhrt-2015-000279

NOACs versus warfarin for stroke prevention in patients with AF: a systematic review and meta-analysis

Tim Hicks, Fiona Stewart, Anne Eisinga

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Abstract

BACKGROUND: Warfarin has been the anticoagulant of choice for the prevention of ischaemic stroke in patients with atrial fibrillation (AF). Novel oral anticoagulants (NOACs) are increasingly used as an alternative.

OBJECTIVES: The objective of this review was to evaluate the efficacy and safety of the NOACs versus warfarin in patients with AF.

SEARCH METHODS: Medline, EMBASE and grey literature search for all phase II and III randomised control trials.

DATA COLLECTION/ANALYSIS: Two authors independently reviewed abstracts and performed data extraction of eligible full-text articles. Revman V.5 was used for meta-analysis.

MAIN RESULTS: 12 studies were identified with a total study population of 77 011. NOACs demonstrated a reduction in the composite of stroke or systemic embolic events OR 0.85 (95% CI 0.75 to 0.98), a 52% reduction in intracranial haemorrhage OR 0.48 (95% CI 0.40 to 0.57) and a 14% reduction in mortality OR 0.86 (0.82 to 0.91). The 30-day end of study switch to warfarin demonstrated an in increase in stroke or systemic embolic events OR 2.60 (95% CI 1.61 to 4.18) and an increase in major bleeding OR 2.19 (95% CI 1.42 to 3.36).

CONCLUSIONS: NOACs are superior to warfarin for the prevention of the composite of stroke and systemic embolism in patients with AF and an additional risk factor for stroke. There is a significant reduction in intracranial haemorrhage, which drives the finding of significantly lower mortality. During the poststudy switch from NOACs to warfarin there is an excess of the composite of stroke and systemic embolism as well as major bleeding events, which may be of significance in clinical practice.

Original language	English
Article number	e000279
Pages (from-to)	1-9
Number of pages	9
Journal	Open Heart
Volume	3
Issue number	1
DOIs	https://doi.org/10.1136/openhrt-2015-000279
Publication status	Published - 2016

Bibliographical note

Acknowledgments
Revman software was used for meta-analysis, a free download from the Cochrane Collaboration. GRADE pro software was used to formulate the GRADE summary of findings table, a free download from the GRADE working group.

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Journal Article

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NOACs versus warfarin for stroke prevention in patients with AF: a systematic review and meta-analysis
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Cite this

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title = "NOACs versus warfarin for stroke prevention in patients with AF: a systematic review and meta-analysis",

abstract = "BACKGROUND: Warfarin has been the anticoagulant of choice for the prevention of ischaemic stroke in patients with atrial fibrillation (AF). Novel oral anticoagulants (NOACs) are increasingly used as an alternative.OBJECTIVES: The objective of this review was to evaluate the efficacy and safety of the NOACs versus warfarin in patients with AF.SEARCH METHODS: Medline, EMBASE and grey literature search for all phase II and III randomised control trials.DATA COLLECTION/ANALYSIS: Two authors independently reviewed abstracts and performed data extraction of eligible full-text articles. Revman V.5 was used for meta-analysis.MAIN RESULTS: 12 studies were identified with a total study population of 77 011. NOACs demonstrated a reduction in the composite of stroke or systemic embolic events OR 0.85 (95% CI 0.75 to 0.98), a 52% reduction in intracranial haemorrhage OR 0.48 (95% CI 0.40 to 0.57) and a 14% reduction in mortality OR 0.86 (0.82 to 0.91). The 30-day end of study switch to warfarin demonstrated an in increase in stroke or systemic embolic events OR 2.60 (95% CI 1.61 to 4.18) and an increase in major bleeding OR 2.19 (95% CI 1.42 to 3.36).CONCLUSIONS: NOACs are superior to warfarin for the prevention of the composite of stroke and systemic embolism in patients with AF and an additional risk factor for stroke. There is a significant reduction in intracranial haemorrhage, which drives the finding of significantly lower mortality. During the poststudy switch from NOACs to warfarin there is an excess of the composite of stroke and systemic embolism as well as major bleeding events, which may be of significance in clinical practice.",

keywords = "Journal Article",

author = "Tim Hicks and Fiona Stewart and Anne Eisinga",

note = "Acknowledgments Revman software was used for meta-analysis, a free download from the Cochrane Collaboration. GRADE pro software was used to formulate the GRADE summary of findings table, a free download from the GRADE working group.",

year = "2016",

doi = "10.1136/openhrt-2015-000279",

language = "English",

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T1 - NOACs versus warfarin for stroke prevention in patients with AF

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AU - Hicks, Tim

AU - Stewart, Fiona

AU - Eisinga, Anne

N1 - Acknowledgments Revman software was used for meta-analysis, a free download from the Cochrane Collaboration. GRADE pro software was used to formulate the GRADE summary of findings table, a free download from the GRADE working group.

PY - 2016

Y1 - 2016

N2 - BACKGROUND: Warfarin has been the anticoagulant of choice for the prevention of ischaemic stroke in patients with atrial fibrillation (AF). Novel oral anticoagulants (NOACs) are increasingly used as an alternative.OBJECTIVES: The objective of this review was to evaluate the efficacy and safety of the NOACs versus warfarin in patients with AF.SEARCH METHODS: Medline, EMBASE and grey literature search for all phase II and III randomised control trials.DATA COLLECTION/ANALYSIS: Two authors independently reviewed abstracts and performed data extraction of eligible full-text articles. Revman V.5 was used for meta-analysis.MAIN RESULTS: 12 studies were identified with a total study population of 77 011. NOACs demonstrated a reduction in the composite of stroke or systemic embolic events OR 0.85 (95% CI 0.75 to 0.98), a 52% reduction in intracranial haemorrhage OR 0.48 (95% CI 0.40 to 0.57) and a 14% reduction in mortality OR 0.86 (0.82 to 0.91). The 30-day end of study switch to warfarin demonstrated an in increase in stroke or systemic embolic events OR 2.60 (95% CI 1.61 to 4.18) and an increase in major bleeding OR 2.19 (95% CI 1.42 to 3.36).CONCLUSIONS: NOACs are superior to warfarin for the prevention of the composite of stroke and systemic embolism in patients with AF and an additional risk factor for stroke. There is a significant reduction in intracranial haemorrhage, which drives the finding of significantly lower mortality. During the poststudy switch from NOACs to warfarin there is an excess of the composite of stroke and systemic embolism as well as major bleeding events, which may be of significance in clinical practice.

AB - BACKGROUND: Warfarin has been the anticoagulant of choice for the prevention of ischaemic stroke in patients with atrial fibrillation (AF). Novel oral anticoagulants (NOACs) are increasingly used as an alternative.OBJECTIVES: The objective of this review was to evaluate the efficacy and safety of the NOACs versus warfarin in patients with AF.SEARCH METHODS: Medline, EMBASE and grey literature search for all phase II and III randomised control trials.DATA COLLECTION/ANALYSIS: Two authors independently reviewed abstracts and performed data extraction of eligible full-text articles. Revman V.5 was used for meta-analysis.MAIN RESULTS: 12 studies were identified with a total study population of 77 011. NOACs demonstrated a reduction in the composite of stroke or systemic embolic events OR 0.85 (95% CI 0.75 to 0.98), a 52% reduction in intracranial haemorrhage OR 0.48 (95% CI 0.40 to 0.57) and a 14% reduction in mortality OR 0.86 (0.82 to 0.91). The 30-day end of study switch to warfarin demonstrated an in increase in stroke or systemic embolic events OR 2.60 (95% CI 1.61 to 4.18) and an increase in major bleeding OR 2.19 (95% CI 1.42 to 3.36).CONCLUSIONS: NOACs are superior to warfarin for the prevention of the composite of stroke and systemic embolism in patients with AF and an additional risk factor for stroke. There is a significant reduction in intracranial haemorrhage, which drives the finding of significantly lower mortality. During the poststudy switch from NOACs to warfarin there is an excess of the composite of stroke and systemic embolism as well as major bleeding events, which may be of significance in clinical practice.

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U2 - 10.1136/openhrt-2015-000279

DO - 10.1136/openhrt-2015-000279

M3 - Article

C2 - 26848392

VL - 3

SP - 1

EP - 9

JO - Open Heart

JF - Open Heart

IS - 1

M1 - e000279

ER -

NOACs versus warfarin for stroke prevention in patients with AF: a systematic review and meta-analysis

Abstract

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