4.7 Article

Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation and Valvular Heart Disease

Journal

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
Volume 69, Issue 11, Pages 1363-1371

Publisher

ELSEVIER SCIENCE INC
DOI: 10.1016/j.jacc.2016.12.038

Keywords

atrial fibrillation; bleeding; death; major bleeding; stroke; systemic embolism; valvular heart disease

Funding

  1. Boehringer Ingelheim
  2. Daiichi-Sankyo
  3. Bayer
  4. Merck
  5. Bristol-Myers Squibb
  6. Portola
  7. Pfizer
  8. Bristol-Myers Squibb/Pfizer
  9. Roche

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BACKGROUND Valvular heart disease (VHD) and atrial fibrillation (AF) often coexist. Phase III trials comparing non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin excluded patients with moderate/severe mitral stenosis or mechanical heart valves, but variably included patients with other VHD and valve surgeries. OBJECTIVES This study aimed to determine relative safety and efficacy of NOACs in patients with VHD. METHODS We performed a meta-analysis of the 4 phase III AF trials of the currently available NOACs versus warfarin in patients with coexisting VHD to assess pooled estimates of relative risk (RR) and 95% confidence intervals (CIs) for stroke/systemic embolic events (SSEE), major bleeding, intracranial hemorrhage (ICH), and all-cause death. RESULTS Compared with warfarin, the rate of SSEE in patients treated with higher-dose NOACs was lower and consistent among 13,585 patients with (RR: 0.70; 95% CI: 0.58 to 0.86) or 58,098 without VHD (RR: 0.84; 95% CI: 0.75 to 0.95; interaction p = 0.13). Major bleeding in patients on higher-dose NOACs versus warfarin was similar and consistent among patients with (RR: 0.93; 95% CI: 0.68 to 1.27) or without VHD (RR: 0.85; 95% CI: 0.70 to 1.02; interaction p = 0.63 for VHD/no-VHD difference). Intracranial hemorrhage was lower with higher-dose NOACs than with warfarin irrespective of VHD (RR: 0.47; 95% CI: 0.24 to 0.93, and 0.49; 95% CI: 0.41 to 059, respectively; interaction p = 0.91). No protective effect of higher-dose NOACs in preventing all-cause death seemed to be present in patients with VHD versus without VHD (RR: 1.01; 95% CI: 0.90 to 1.14 vs. RR: 0.88; 95% CI: 0.82 to 0.94, respectively; interaction p = 0.03). CONCLUSIONS High-dose NOACs provide overall efficacy and safety similar in AF patients with or without VHD. (J Am Coll Cardiol 2017; 69: 1363-71) (C) 2017 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons. org/licenses/by-nc-nd/4.0/).

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