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Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic Review.

Publication ,  Journal Article
Lowenstern, A; Al-Khatib, SM; Sharan, L; Chatterjee, R; Allen LaPointe, NM; Shah, B; Borre, ED; Raitz, G; Goode, A; Yapa, R; Davis, JK ...
Published in: Ann Intern Med
December 4, 2018

BACKGROUND: The comparative safety and effectiveness of treatments to prevent thromboembolic complications in atrial fibrillation (AF) remain uncertain. PURPOSE: To compare the effectiveness of medical and procedural therapies in preventing thromboembolic events and bleeding complications in adults with nonvalvular AF. DATA SOURCES: English-language studies in several databases from 1 January 2000 to 14 February 2018. STUDY SELECTION: Two reviewers independently screened citations to identify comparative studies of treatments to prevent stroke in adults with nonvalvular AF who reported thromboembolic or bleeding complications. DATA EXTRACTION: Two reviewers independently abstracted data, assessed study quality and applicability, and rated strength of evidence. DATA SYNTHESIS: Data from 220 articles were included. Dabigatran and apixaban were superior and rivaroxaban and edoxaban were similar to warfarin in preventing stroke or systemic embolism. Apixaban and edoxaban were superior and rivaroxaban and dabigatran were similar to warfarin in reducing the risk for major bleeding. Treatment effects with dabigatran were similar in patients with renal dysfunction (interaction P > 0.05), and patients younger than 75 years had lower bleeding rates with dabigatran (interaction P < 0.001). The benefit of treatment with apixaban was consistent in many subgroups, including those with renal impairment, diabetes, and prior stroke (interaction P > 0.05 for all). The greatest bleeding risk reduction was observed in patients with a glomerular filtration rate less than 50 mL/min/1.73 m2 (P = 0.003). Similar treatment effects were observed for rivaroxaban and edoxaban in patients with prior stroke, diabetes, or heart failure (interaction P > 0.05 for all). LIMITATION: Heterogeneous study populations, interventions, and outcomes. CONCLUSION: The available direct-acting oral anticoagulants (DOACs) are at least as effective and safe as warfarin for patients with nonvalvular AF. The DOACs had similar benefits across several patient subgroups and seemed safe and efficacious for a wide range of patients with nonvalvular AF. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42017069999).

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Published In

Ann Intern Med

DOI

EISSN

1539-3704

Publication Date

December 4, 2018

Volume

169

Issue

11

Start / End Page

774 / 787

Location

United States

Related Subject Headings

  • Thromboembolism
  • Stroke
  • Septal Occluder Device
  • Humans
  • Hemorrhage
  • General & Internal Medicine
  • Factor Xa Inhibitors
  • Comparative Effectiveness Research
  • Atrial Fibrillation
  • Atrial Appendage
 

Citation

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ICMJE
MLA
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Lowenstern, A., Al-Khatib, S. M., Sharan, L., Chatterjee, R., Allen LaPointe, N. M., Shah, B., … Sanders, G. D. (2018). Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic Review. Ann Intern Med, 169(11), 774–787. https://doi.org/10.7326/M18-1523
Lowenstern, Angela, Sana M. Al-Khatib, Lauren Sharan, Ranee Chatterjee, Nancy M. Allen LaPointe, Bimal Shah, Ethan D. Borre, et al. “Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic Review.Ann Intern Med 169, no. 11 (December 4, 2018): 774–87. https://doi.org/10.7326/M18-1523.
Lowenstern A, Al-Khatib SM, Sharan L, Chatterjee R, Allen LaPointe NM, Shah B, et al. Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic Review. Ann Intern Med. 2018 Dec 4;169(11):774–87.
Lowenstern, Angela, et al. “Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic Review.Ann Intern Med, vol. 169, no. 11, Dec. 2018, pp. 774–87. Pubmed, doi:10.7326/M18-1523.
Lowenstern A, Al-Khatib SM, Sharan L, Chatterjee R, Allen LaPointe NM, Shah B, Borre ED, Raitz G, Goode A, Yapa R, Davis JK, Lallinger K, Schmidt R, Kosinski AS, Sanders GD. Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic Review. Ann Intern Med. 2018 Dec 4;169(11):774–787.

Published In

Ann Intern Med

DOI

EISSN

1539-3704

Publication Date

December 4, 2018

Volume

169

Issue

11

Start / End Page

774 / 787

Location

United States

Related Subject Headings

  • Thromboembolism
  • Stroke
  • Septal Occluder Device
  • Humans
  • Hemorrhage
  • General & Internal Medicine
  • Factor Xa Inhibitors
  • Comparative Effectiveness Research
  • Atrial Fibrillation
  • Atrial Appendage