Efficacy and Safety of Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Liver Disease: a Meta-Analysis and Systematic Review.

BACKGROUND: Liver disease is associated with increased bleeding risk. The efficacy and safety of direct oral anticoagulants (DOACs) is a subject of contention in atrial fibrillation (AF) patients with liver disease. METHODS: Electronic databases (PubMed, Embase, and Cochrane Library) were searched to retrieve studies on the efficacy and safety of DOACs versus warfarin in AF patients with liver disease from January 1980 to April 2020. A meta-analysis was conducted using a random-effects model. RESULTS: Six studies involving 41,859 patients were included. Compared with warfarin, DOACs demonstrated significant reduction in ischemic stroke (HR, 0.68; 95% CI (0.54-0.86)), major bleeding (0.74 (0.59-0.92)), and intracranial hemorrhage (ICH) (0.48 (0.40-0.58)), with no significant effect on gastrointestinal bleeding (P = 0.893) in AF patients with liver disease. Similar results were observed in regular-dose, reduced-dose, and active liver disease subgroups, albeit Asian patients had a slight reduction in major bleeding (P = 0.055). Furthermore, the pooled estimates of individual DOAC subgroups indicated that dabigatran and apixaban led to greater safety in major bleeding (P < 0.001), ICH (P < 0.001), and gastrointestinal bleeding (P < 0.005) in these patients. The same trends were observed in AF patients with cirrhosis. CONCLUSIONS: Our findings suggest that DOACs significantly reduce the risk of ischemic stroke, major bleeding, and ICH, with no significant effect on the risk of gastrointestinal bleeding in AF patients with liver disease compared with warfarin.

Triple versus dual oral antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention: a systematic review and meta-analysis.

BACKGROUND: The efficacy and safety of dual therapy (dual antiplatelet therapy [DAPT] and warfarin plus single antiplatelet [WS]) versus triple therapy (TT, DAPT plus warfarin) are still debated in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). The purpose of this study was to determine the optimal antithrombotic strategy. METHODS: Electronic databases (PubMed, Embase, Cochrane Library, CNKI and WanFang Data) were searched to retrieve studies on the efficacy and safety of TT vs. dual therapy in patients with AF undergoing PCI until August 2017. A meta-analysis was conducted using a random-effects model. The primary efficacy and safety endpoints were major adverse cardiac events (MACEs) and major bleeding events. RESULTS: Twenty-four studies involving 21,167 patients were included. The TT group had a significantly lower risk of MACEs (P=0.024) but a higher risk of major bleeding (P<0.001). In TT vs. DAPT subgroup, TT was associated with a lower risk of MI and stent thrombosis in Asian patients and a lower risk of stroke in non-Asian patients. Furthermore, TT did not decrease MACEs incidence (P=0.458) but increased the risk of major bleeding (P=0.008) relative to WS. The same trends were observed in Asian and non-Asian patients. CONCLUSION: Patients with AF undergoing PCI who received TT had significant reduction in MACEs but increased the risk of major bleeding compared with DAPT. However, WS had a similar efficacy but reduced the risk of major bleeding compared with TT. Current evidence suggests that TT might not be required and might be replaced by WS.