Biondi-Zoccai G, Malavasi V, D'Ascenzo F, Abbate A, Agostoni P, Lotrionte M, Castagno D, Van Tassell B, Casali E, Marietta M, Modena M G, Ellenbogen K A, Frati G
Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy.
HSR Proc Intensive Care Cardiovasc Anesth. 2013;5(1):40-54.
Novel oral anticoagulants have been tested against warfarin for atrial fibrillation, yet no direct comparison is available. We thus aimed to perform pair-wise (direct) and warfarin-adjusted network (i.e. indirect) meta-analyses of novel oral anticoagulants for atrial fibrillation.
Databases were searched for randomized warfarin-controlled trials of novel anticoagulants for non-valvular atrial fibrillation. The primary end-point was long-term stroke/systemic embolism. Odds ratios (95% intervals) were computed with RevMan and WinBUGS.
Seven trials (52701 patients) were included, focusing on apixaban, dabigatran, edoxaban and rivaroxaban. Pair-wise meta-analysis showed that after a weighted average of 23 months these novel anticoagulants lead to significant reductions in the risk of stroke/systemic embolism (odds ratio=0.81 [0.71-0.92], I2=23%) and all cause death (odds ratio=0.88 [0.82-0.95], I2=0%) in comparison to warfarin. Network meta-analysis showed that apixaban and dabigatran proved similarly superior to warfarin in preventing stroke/systemic embolism (odds ratio=0.78 [0.62-0.96] for apixaban vs warfarin; odds ratio=0.66 [0.52-0.84] for high-dose dabigatran vs warfarin; odds ratio for apixaban vs high-dose dabigatran=1.17 [0.85-1.63]), but apixaban was associated with fewer major bleedings (odds ratio=0.73 [0.57-0.93]) and drug discontinuations (odds ratio=0.64 [0.52-0.78]) than dabigatran. Rivaroxaban did not reduce stroke/systemic embolism (odds ratio=0.87 [0.71-1.07]) or major bleedings in comparison to warfarin (odds ratio=0.87 [0.71-1.07]) and was associated with more major bleedings in comparison to apixaban (odds ratio=1.52 [1.19-1.92]). Data for edoxaban were inconclusive.
Novel oral anticoagulants appear as a very promising treatment option for atrial fibrillation.
新型口服抗凝药已针对华法林用于房颤进行了测试，但尚无直接比较。因此，我们旨在对新型口服抗凝药用于房颤进行两两（直接）和华法林调整网络（即间接）荟萃分析。
检索数据库中关于新型抗凝药用于非瓣膜性房颤的随机华法林对照试验。主要终点是长期卒中/全身性栓塞。使用RevMan和WinBUGS计算比值比（95%区间）。
纳入七项试验（52701例患者），重点关注阿哌沙班、达比加群、依度沙班和利伐沙班。两两荟萃分析显示，在加权平均23个月后，与华法林相比，这些新型抗凝药可显著降低卒中/全身性栓塞风险（比值比=0.81[0.71 - 0.92]，I² = 23%）和全因死亡风险（比值比=0.88[0.82 - 0.95]，I² = 0%）。网络荟萃分析显示，阿哌沙班和达比加群在预防卒中/全身性栓塞方面被证明同样优于华法林（阿哌沙班与华法林相比，比值比=0.78[0.62 - 0.96]；高剂量达比加群与华法林相比，比值比=0.66[0.52 - 0.84]；阿哌沙班与高剂量达比加群相比，比值比=1.17[0.85 - 1.63]），但与达比加群相比，阿哌沙班的大出血（比值比=0.73[0.57 - 0.93]）和停药（比值比=0.64[0.52 - 0.78]）较少。与华法林相比，利伐沙班未降低卒中/全身性栓塞（比值比=0.87[0.71 - 1.07]）或大出血（比值比=0.87[0.71 - 1.07]），且与阿哌沙班相比，大出血更多（比值比=1.52[1.19 - 1.92]）。依度沙班的数据尚无定论。
新型口服抗凝药似乎是房颤非常有前景的治疗选择。
