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Comparison of the Efficacy and Safety of Direct Oral Anticoagulants and Vitamin K Antagonists in Patients with Atrial Fibrillation and Concomitant Liver Cirrhosis: A Systematic Review and Meta-Analysis

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Abstract

Background

Patients with atrial fibrillation (AF) have a higher risk of developing thromboembolic events. Current guidelines recommend the use of oral anticoagulants for stroke prevention in these patients. Several clinical trials demonstrated that direct oral anticoagulants (DOACs) have similar efficacy and are safer alternatives to traditional oral anticoagulants. However, patients with concomitant liver cirrhosis were excluded from these trials.

Objective

We aimed to systematically identify and review published clinical studies on the use of DOACs in patients with AF and liver cirrhosis and assess the efficacy and safety of DOACs in these patients.

Methods

A systematic review of clinical trials and retrospective studies was conducted by searching the PubMed, Cochrane Library, Embase, SCOPUS, and Web of Science databases up to September 2020.

Results

Three retrospective studies were included, involving 4011 patients with AF and liver cirrhosis. The use of DOACs was associated with a significant reduction in ischemic stroke (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.42–0.90; p = 0.01), major bleeding events (HR 0.64; 95% CI 0.57–0.72; p < 0.001), and intracranial hemorrhage (HR 0.49; 95% CI 0.40–0.59; p < 0.001).

Conclusions

Compared with warfarin in patients with AF and liver cirrhosis, DOACs appear to be associated with improved efficacy and safety outcomes. Randomized controlled trials are warranted to confirm these findings.

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Author notes

  1. Zhi-Yan Lee and Boon-Hao Suah contributed equally.

Authors and Affiliations

  1. Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Zhi-Yan Lee, Boon-Hao Suah, Yao Hao Teo, Yao Neng Teo, Nicholas L. X. Syn, Tiong-Cheng Yeo, Raymond C. C. Wong, Ping Chai, Yu Jun Wong, Leonard L. L. Yeo, Benjamin Y. Q. Tan & Ching-Hui Sia

  2. Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore, 119228, Singapore

    Tiong-Cheng Yeo, Raymond C. C. Wong, Ping Chai & Ching-Hui Sia

  3. Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore

    Yu Jun Wong

  4. School of Clinical Medicine, University of Cambridge, Cambridge, UK

    Jamie S. Y. Ho

  5. Internal Medicine Residency, National University Health System, Singapore, Singapore

    Aloysius Sheng-Ting Leow

  6. Division of Neurology, University Medicine Cluster, National University Health System, Singapore, Singapore

    Leonard L. L. Yeo & Benjamin Y. Q. Tan

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Correspondence to Ching-Hui Sia.

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Funding

CHS was supported by the National University of Singapore Yong Loo Lin School of Medicine’s Junior Academic Faculty Scheme.

Conflict of interest

Zhi-Yan Lee, Boon-Hao Suah, Yao Hao Teo, Yao Neng Teo, Nicholas LX Syn, Tiong-Cheng Yeo, Raymond CC Wong, Ping Chai, Yu Jun Wong, Jamie SY Ho, Aloysius Sheng-Ting Leow, Leonard LL Yeo, Benjamin YQ Tan, and Ching-Hui Sia do not have any potential conflicts of interest that might be relevant to this work.

Ethics approval

There was no direct involvement of patients and the public in the design and conduction of this review as this review was based on published studies. Therefore, formal ethics approval was not required.

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Data used for this study can be accessed upon request to the corresponding author.

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Author contributions

ZYL, BHS, YHT, YNT, NS, and CHS designed the study and developed the study protocol and tools. ZYL, BHS, YHT, YNT, NS, and CHS were responsible for data collection. ZYL, BHS, YHT, YNT, NS, and CHS analyzed data and wrote the manuscript. All authors contributed to the conceptualization of the research questions, interpretation of the results, and manuscript writing. All authors read and approved the final manuscript.

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Lee, ZY., Suah, BH., Teo, Y.H. et al. Comparison of the Efficacy and Safety of Direct Oral Anticoagulants and Vitamin K Antagonists in Patients with Atrial Fibrillation and Concomitant Liver Cirrhosis: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 22, 157–165 (2022). https://doi.org/10.1007/s40256-021-00482-w

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