Journal of Thrombosis and Thrombolysis

, Volume 45, Issue 4, pp 550–556 | Cite as

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

  • Natale Daniele Brunetti
  • Nicola Tarantino
  • Luisa De Gennaro
  • Michele Correale
  • Francesco Santoro
  • Matteo Di Biase


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.


Cardioversion Major bleeding Meta-analysis Non-valvular atrial fibrillation Stroke Systemic embolism Warfarin 


Compliance with ethical standards

Conflict of interest

The authors have no potential conflict of interest to disclose.


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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Medical & Surgical SciencesUniversity of FoggiaFoggiaItaly
  2. 2.Cardiology DepartmentSan Paolo HospitalBariItaly
  3. 3.Ospedali Riuniti University HospitalFoggiaItaly
  4. 4.Asklepios Klinik Sankt GeorgHamburgGermany
  5. 5.Santa Maria HospitalGVM Care & ResearchBariItaly

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