Published online Apr 26, 2021. doi: 10.4330/wjc.v13.i4.82
Peer-review started: December 8, 2020
First decision: February 15, 2021
Revised: February 21, 2021
Accepted: April 13, 2021
Article in press: April 13, 2021
Published online: April 26, 2021
Processing time: 134 Days and 6.6 Hours
Most of the randomized clinical trials that led to the wide use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation (AF) originated from western countries.
To systematically review and quantitatively synthesize the real-world data regarding the efficacy and safety of dabigatran, rivaroxaban, and apixaban compared to warfarin for stroke prevention in Asian patients with non-valvular AF.
Medline, Cochrane, and ClinicalTrial.gov databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. The primary outcome was ischemic stroke. The secondary outcomes were all-cause mortality, major bleeding, intracranial hemorrhage, and gastrointestinal bleeding.
Twelve studies from East Asia or Southeast Asia and 441450 patients were included. Dabigatran, rivaroxaban, and apixaban were associated with a significant reduction in the incidence of ischemic stroke [hazard ratio (HR) = 0.78, 95% confidence interval (CI): 0.65-0.94; HR = 0.79, 95%CI: 0.74-0.85, HR = 0.70, 95%CI: 0.62-0.78; respectively], all-cause mortality (HR = 0.68, 95%CI: 0.56-0.83; HR = 0.66, 95%CI: 0.52-0.84; HR = 0.66, 95%CI: 0.49-0.90; respectively), and major bleeding (HR = 0.61, 95%CI: 0.54-0.69; HR = 0.70, 95%CI: 0.54-0.90; HR = 0.58, 95%CI: 0.43-0.78; respectively) compared to warfarin.
Dabigatran, rivaroxaban, and apixaban appear to be superior to warfarin in both efficacy and safety in Asians with non-valvular AF.
Core Tip: Dabigatran, rivaroxaban, apixaban have better efficacy (reduction in ischemic stroke and all-cause mortality) and are safer (reduction in major bleeding) than warfarin. Dabigatran is associated with a lower rate of intracranial hemorrhage than warfarin, while rivaroxaban and apixaban appear to have a trend towards reduced intracranial hemorrhage, without statistical significance. Dabigatran, rivaroxaban, and apixaban are associated with a lower rate of gastrointestinal bleeding.