Non-vitamin K antagonist oral anticoagulants in the cardioversion of patients with atrial fibrillation: systematic review and meta-analysis
Non-vitamin K antagonist oral anticoagulants (NOACs) are at least non-inferior to Vitamin K Antagonists (VKAs) for stroke prevention on patients with non-valvular atrial fibrillation (AF). We aimed to evaluate the efficacy and safety of NOACs in patients undergoing cardioversion through a systematic review and meta-analysis.
MEDLINE, Cochrane Library, and Web of Science® databases (until September 2014) were searched for studies fulfilling inclusion criteria. Two reviewers independently selected randomized controlled trials (RCTs) evaluating NOACs and VKA in patients with AF undergoing cardioversion. The primary outcome was ischemic stroke or systemic embolism (IS/SE). Secondary outcomes were major bleeding, myocardial infarction, and mortality. Risk ratio (RR) and 95 % confidence intervals were derived through random-effects meta-analysis. Heterogeneity was evaluated through I 2 test.
Four RCTs (3 post-hoc analysis) evaluating apixaban, dabigatran, and rivaroxaban in 3,512 patients with AF were included. The risk of IS/SE with NOACs was similar to VKA (RR 0.60, 95 % CI 0.20–1.80; I 2 = 17 %). There was no significant increase in major bleeding (RR 1.27, 95 % CI 0.58–2.81; I 2 = 0 %), myocardial infarction (RR 0.71, 95 % CI 0.10–5.04; I 2 = 0 %), or mortality (RR 0.87, 95 % CI 0.24–3.08; I 2 = 0 %) with NOACs.
This systematic review and meta-analysis suggests that NOACs may be as safe as VKAs in the setting of AF cardioversion.
KeywordsMeta-analysis Electric countershock Stroke Anticoagulants Cardioversion Transesophageal echocardiography
We thank the Portuguese Collaborating Center of the Iberoamerican Cochrane Network. This was an academic project not funded by any government or non-government grant.
Conflict of interest
DC, and JC do not have any competing interests to disclose. JJF had speaker and consultant fees with GlaxoSmithKline, Novartis, TEVA, Lundbeck, Solvay, Abbott, Bial, Merck-Serono, Grunenthal, and Merck Sharp and Dohme. GYHL had consultant fees from Bayer, Astellas, Merck, Astra Zeneca, Sanofi, BMS/Pfizer, Biotronik, Portola, and Boehringer Ingelheim; and has been on the speakers bureau for Bayer, BMS/Pfizer, Boehringer Ingelheim, and Sanofi-Aventis. FJP had consultant and speaker fees with Astra Zeneca, Bayer, and Boehringer Ingelheim.
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