Non-valvular atrial fibrillation (NVAF) is the most common arrhythmia. Patients with NVAF are at increased risk of stroke, therefore we evaluated the efficacy and safety of different approaches to prevent this major complication.
They conducted electronic database searches of phase III randomized controlled trials (RCT). The groups were novel oral anticoagulants (NOAC), Watchman left atrial appendage occlusion device (DEVICE), and warfarin. Efficacy outcomes were stroke and/or systemic embolism (SSE), and all-cause mortality. Safety outcome was major bleeding and/or procedure related complications. A sub-group analysis of the elderly population was done. We used random-effects model to compare pooled outcomes and tested for heterogeneity. Odds ratios (OR) and 95% confidence intervals (CI) were computed for each outcome. Seven RCTs (n=73,978) were included. There was a significant difference favoring NOAC for SSE (OR 0.84, 95% CI 0.72-0.97; p=0.01), all-cause mortality (OR 0.89, 95% CI 0.84-0.94; p<0.001) and safety outcomes (OR 0.79, 95% CI 0.65-0.97; p=0.026) compared to warfarin. No difference was seen between DEVICE and warfarin for efficacy endpoints, however DEVICE had more complications (OR 1.85, 95% CI 1.14-3.01; p=0.012). In the elderly (6 RCTs, n=30,699), SSE was favored with NOAC over warfarin (OR 0.77, 95% CI 0.68-0.87; p=<0.001). No evidence of significant publication bias was found.
NOAC is superior to warfarin for stroke prevention in NVAF. This benefit was also observed in the elderly population. DEVICE is a reasonable non-inferior alternative to warfarin for stroke prevention, but cautious use is essential given safety concerns.
Left Atrial Appendage Occlusion Device and Novel Oral Anticoagulants Versus Warfarin for Stroke Prevention in Non-Valvular Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Control Trials
Circ Arrhythm Electrophysiol 2015 Jul 30;[EPub Ahead of Print], DF Briceno, P Villablanca Spinetto, N Cyrille, D Massera, E Bader, E Manheimer, P Aagaard, K Ferrick, J Gross, SG Kim, A Krumerman, E Palma, N Guttenplan, J Romero, J Fisher, M Garcia, A Natale, L Di Biase