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J Am Heart Assoc. 2016 May 20;5(5). pii: e003206. doi: 10.1161/JAHA.116.003206.

Comparative Effectiveness of Interventions for Stroke Prevention in Atrial Fibrillation: A Network Meta-Analysis.

Author information

1
Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR tereshch@ohsu.edu.
2
Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR.
3
University of Rochester School of Medicine & Dentistry and The Arrhythmia Institute of The Valley Health System, New York, NY University of Rochester School of Medicine & Dentistry and The Arrhythmia Institute of The Valley Health System, Ridgewood, NJ.

Abstract

BACKGROUND:

The goal of this study was to compare the safety and effectiveness of individual antiembolic interventions in nonvalvular atrial fibrillation (AF): novel oral anticoagulants (NOACs) (apixaban, dabigatran, edoxaban, and rivaroxaban); vitamin K antagonists (VKA); aspirin; and the Watchman device.

METHODS AND RESULTS:

A network meta-analysis of randomized, clinical trials (RCTs) was performed. RCTs that included patients with prosthetic cardiac valves or mitral stenosis, mean or median follow-up <6 months, <200 participants, without published report in English language, and NOAC phase II studies were excluded. The placebo/control arm received either placebo or no treatment. The primary efficacy outcome was the combination of stroke (of any type) and systemic embolism. All-cause mortality served as a secondary efficacy outcome. The primary safety outcome was the combination of major extracranial bleeding and intracranial hemorrhage. A total of 21 RCTs (96 017 nonvalvular AF patients; median age, 72 years; 65% males; median follow-up, 1.7 years) were included. In comparison to placebo/control, use of aspirin (odds ratio [OR], 0.75 [95% CI, 0.60-0.95]), VKA (0.38 [0.29-0.49]), apixaban (0.31 [0.22-0.45]), dabigatran (0.29 [0.20-0.43]), edoxaban (0.38 [0.26-0.54]), rivaroxaban (0.27 [0.18-0.42]), and the Watchman device (0.36 [0.16-0.80]) significantly reduced the risk of any stroke or systemic embolism in nonvalvular AF patients, as well as all-cause mortality (aspirin: OR, 0.82 [0.68-0.99]; VKA: 0.69 [0.57-0.85]; apixaban: 0.62 [0.50-0.78]; dabigatran: 0.62 [0.50-0.78]; edoxaban: 0.62 [0.50-0.77]; rivaroxaban: 0.58 [0.44-0.77]; and the Watchman device: 0.47 [0.25-0.88]). Apixaban (0.89 [0.80-0.99]), dabigatran (0.90 [0.82-0.99]), and edoxaban (0.89 [0.82-0.96]) reduced risk of all-cause death as compared to VKA.

CONCLUSIONS:

The entire spectrum of therapy to prevent thromboembolism in nonvalvular AF significantly reduced stroke/systemic embolism events and mortality.

KEYWORDS:

anticoagulation; atrial fibrillation; comparative effectiveness; left atrial appendage; nonvalvular; oral anticoagulants; stroke; vitamin K antagonists; watchman

PMID:
27207998
PMCID:
PMC4889191
DOI:
10.1161/JAHA.116.003206
[Indexed for MEDLINE]
Free PMC Article

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