DOACs vs warfarin in AF with comorbid CKD or valvular disease: a systematic review and meta-analysis

Direct oral anticoagulant agents (DOACs) are indicated to prevent vascular events in patients with atrial fibrillation (AF) without concomitant valvular disease or severe chronic kidney disease (CKD), groups in which warfarin is the preferred choice. We aimed to evaluate the safety of DOACs in these populations compared to warfarin. We conducted a systematic review in MEDLINE, Embase, and Evidence Based Medicine Reviews to identify randomized-controlled trials (RCTs) and non-RCTs assessing warfarin or DOACs (rivaroxaban, dabigatran, apixaban, or edoxaban) in patients with AF with concomitant valvular disease or CKD (according to Kidney Disease Outcomes Quality Initiative guidelines) that reported on bleeding, stroke, or systemic/arterial thromboembolism. Meta-analysis was performed for eligible studies using the Mantel-Haenszel method random effects model. Of 3172 screened studies, we included 110 studies (310 478 patients with concomitant AF and CKD; 99 299 patients with concomitant AF and valve disease). Meta-analysis showed that, compared to warfarin, in patients with concomitant AF and CKD, DOACs were associated with reduced bleeding (odds ratio [OR], 0.66; 95% confidence interval [Cl], 0.49-0.88; <i>P</i> = .005) and strokes (OR, 0.60; 95% CI, 0.43-0.85; <i>P</i> = .004), particularly in patients with stages 4 and 5 CKD and dialysis patients. In patients with concomitant AF and valvular disease, DOACs were associated with reduced bleeding (OR, 0.75; 95% CI, 0.57-0.97; <i>P</i> = .03) and stroke incidence (OR, 0.66; 95% CI, 0.47-0.93; <i>P</i> = .02). Differences were noted for RCTs and non-RCTs. Our findings suggest that DOACs may be equivalent or superior to warfarin both in the prevention of thromboembolic events and reduction of bleeding in these patients.