Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York.
Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, New York.
Am J Cardiol. 2019 Jun 15;123(12):2051-2057. doi: 10.1016/j.amjcard.2019.02.060. Epub 2019 Mar 18.
Older patients with atrial fibrillation (AF) are at higher risk of thromboembolic events and oral anticoagulant (OAC)-related bleeding complications. This meta-analysis evaluates the efficacy and safety of direct-acting OACs (DOACs) compared with warfarin in older patients with nonvalvular AF. PubMed, Embase, and Cochrane Central databases were searched for randomized controlled trials assessing the efficacy and safety of DOACs compared with warfarin in AF patients who were >75 years old. Treatment effects and relevant standard errors were calculated from the available data. These values were imputed in software R to perform meta-analysis through generic inverse variance method. Additionally, we performed a network meta-analysis to compare the relative efficacy and safety of each OAC. Five substudies of randomized controlled trials, comprising 28,135 older participants, were included in the analysis. DOACs as a group were found to have superior efficacy compared with warfarin in reducing stroke or systemic embolization (hazard ratio 0.76, 95% confidence intervals 0.67 to 0.86, p <0.01). The rate of major bleeding was similar, but intracranial hemorrhage was significantly lower in patients randomized to a DOAC (hazard ratio 0.48, 95% confidence intervals 0.34 to 0.67, p <0.01). Apixaban was the only DOAC that significantly reduced all 3 outcomes of systemic embolization, major bleeding, and intracranial hemorrhage compared with warfarin (by 29%, 36%, and 66%, respectively). In conclusion, DOACs were found to be safer and more effective than warfarin for the treatment of nonvalvular AF in older patients. Apixaban appears to provide the best combination of efficacy and safety in this population.
老年心房颤动（AF）患者发生血栓栓塞事件和口服抗凝剂（OAC）相关出血并发症的风险较高。本荟萃分析评估了直接作用的 OAC（DOAC）与华法林相比，在非瓣膜性 AF 老年患者中的疗效和安全性。通过检索 PubMed、Embase 和 Cochrane 中央数据库，评估了 DOAC 与华法林在年龄>75 岁的 AF 患者中的疗效和安全性的随机对照试验。从可用数据中计算了治疗效果和相关标准误差。这些值在软件 R 中进行了插补，通过通用逆方差法进行荟萃分析。此外，我们还进行了网络荟萃分析，以比较每种 OAC 的相对疗效和安全性。分析纳入了 5 项随机对照试验的亚研究，共 28135 名老年参与者。结果显示，DOAC 作为一组药物，在降低卒中或全身性栓塞（风险比 0.76，95%置信区间 0.67 至 0.86，p<0.01）方面优于华法林。大出血发生率相似，但随机分配到 DOAC 的患者颅内出血显著降低（风险比 0.48，95%置信区间 0.34 至 0.67，p<0.01）。阿哌沙班是唯一一种与华法林相比显著降低全身性栓塞、大出血和颅内出血这 3 个结局的 DOAC（分别降低 29%、36%和 66%）。总之，DOAC 比华法林治疗老年非瓣膜性 AF 更安全、更有效。阿哌沙班在该人群中似乎提供了最佳的疗效和安全性组合。
