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Direct oral anti-coagulants compared to vitamin-K antagonists in cardioversion of atrial fibrillation: an updated meta-analysis

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Abstract

Pharmacological or electrical cardioversion allows immediate symptoms improvement in the setting of paroxysmal or persistent atrial fibrillation (AF), although the periprocedural risk of systemic embolism should be considered. Recently, there was a great interest on the safety and efficacy of direct oral anticoagulants (DOACs) when used for the cardioversion of non-valvular AF. We performed a random-effects meta-analysis of patients undergoing both electrical and pharmacologic cardioversion for non-valvular AF in the RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE AF-TIMI 48, X-VeRT, ENSURE-AF, and EMANATE trials. We assessed Mantel–Haenszel pooled estimates of risk ratios (RRs) and 95% confidence intervals (CIs) for stroke/systemic embolism (SSE) and major bleeding (MB) at follow-up. A total of 8564 patients have been included in the analysis. When compared with patients receiving vitamin-K antagonists (VKAs), patients receiving DOACs had a lower risk of SSE (RR 0.70, 95% CI 0.33–1.546, P = 0.34), as well as of MB (RR 0.86;,95% CI 0.47–1.58, P = 0.62), although both were non-significant. Funnel plot analysis showed, however, lower RRs with more recent ad hoc studies in comparison with registrational studies, even though statistical significance was not reached. DOACs are as effective and as safe as VKAs for thromboembolic prevention in non-valvular AF in the setting of cardioversion. There are differences, although non-significant, between registrational studies and studies enrolling exclusively patients undergoing cardioversion of AF.

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Authors and Affiliations

  1. Department of Medical & Surgical Sciences, University of Foggia, Foggia, Italy

    Natale Daniele Brunetti, Nicola Tarantino & Francesco Santoro

  2. Cardiology Department, San Paolo Hospital, Bari, Italy

    Luisa De Gennaro

  3. Ospedali Riuniti University Hospital, Foggia, Italy

    Michele Correale

  4. Asklepios Klinik Sankt Georg, Hamburg, Germany

    Francesco Santoro

  5. Santa Maria Hospital, GVM Care & Research, Bari, Italy

    Matteo Di Biase

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  1. Natale Daniele Brunetti
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  2. Nicola Tarantino
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  4. Michele Correale
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Correspondence to Natale Daniele Brunetti.

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Brunetti, N.D., Tarantino, N., De Gennaro, L. et al. Direct oral anti-coagulants compared to vitamin-K antagonists in cardioversion of atrial fibrillation: an updated meta-analysis. J Thromb Thrombolysis 45, 550–556 (2018). https://doi.org/10.1007/s11239-018-1622-5

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  • DOI: https://doi.org/10.1007/s11239-018-1622-5

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