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Direct Oral Anticoagulants Versus Vitamin K Antagonists in Patients Undergoing Cardioversion for Atrial Fibrillation: a Systematic Review and Meta-analysis

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Abstract

Background

Clinical guidelines recommend peri-cardioversion anticoagulation in patients with atrial fibrillation (AF). We performed a systematic review and meta-analysis to compare the safety and efficacy of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients with AF undergoing cardioversion.

Methods

We searched CENTRAL, MEDLINE, and EMBASE for randomized controlled trials (RCTs) and observational studies comparing DOACs to VKAs in patients undergoing cardioversion for AF. We performed title, abstract, and full-text screening, data extraction, and risk of bias evaluation independently and in duplicate. We pooled data using a random effects model and evaluated the overall quality of evidence using Grading of Recommendations Assessment, Development and Evaluation.

Results

We identified three eligible RCTs (n = 5203) and 21 observational studies (n = 11,855). The three RCTs and four observational studies were at low risk of bias. In RCTs (mean follow-up, 30 days), thromboembolic events occurred in 0.18% of patients receiving DOACs, as compared with 0.55% receiving VKAs (relative risk [RR] 0.40, 95% CI [0.13, 1.24], moderate quality). Major bleeding occurred in 0.42% of patients receiving DOACs as compared with 0.64% receiving VKAs (RR 0.62, 95% CI [0.28, 1.35], moderate quality), and death occurred in 0.28% of patients receiving DOACs as compared with 0.38% receiving VKAs (RR 0.70, 95% CI [0.23, 2.10], low quality). Confidence in the estimates of effect for observational studies was very low.

Conclusion

DOACs peri-cardioversion in patients with AF appears safe from both a bleeding and thromboembolic risk perspective. Available evidence supports the use of DOACs as standard of care peri-cardioversion in patients with AF.

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Authors and Affiliations

  1. Department of Surgery, McMaster University, Hamilton, Ontario, Canada

    Saurabh Gupta & Richard P. Whitlock

  2. Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada

    Saurabh Gupta, William F. McIntyre, Richard P. Whitlock & Emilie P. Belley-Cote

  3. Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada

    Kevin J. Um

  4. Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada

    Arjun Pandey, Marina Ivanova, Yasamin Allahverdi & Parisa Agahi

  5. Department of Medicine, McMaster University, Hamilton, Ontario, Canada

    William F. McIntyre & Emilie P. Belley-Cote

  6. Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada

    Feny Pandya, Ana Lopez & Amrit Sachdeva

  7. Population Health Research Institute, Hamilton, Ontario, Canada

    Richard P. Whitlock & Emilie P. Belley-Cote

  8. David Braley Cardiac, Vascular and Stroke Research Institute, 237 Barton St. E., Hamilton, Ontario, L8L 2X2, Canada

    Emilie P. Belley-Cote

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  1. Saurabh Gupta
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Gupta, S., Um, K.J., Pandey, A. et al. Direct Oral Anticoagulants Versus Vitamin K Antagonists in Patients Undergoing Cardioversion for Atrial Fibrillation: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 33, 339–352 (2019). https://doi.org/10.1007/s10557-019-06869-x

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