Association of Oral Anticoagulation With Stroke in Atrial Fibrillation or Heart Failure: A Comparative Meta-Analysis.
anticoagulants
atrial fibrillation
heart failure
odds ratio
uncertainty
Journal
Stroke
ISSN: 1524-4628
Titre abrégé: Stroke
Pays: United States
ID NLM: 0235266
Informations de publication
Date de publication:
10 2021
10 2021
Historique:
pubmed:
21
7
2021
medline:
7
1
2022
entrez:
20
7
2021
Statut:
ppublish
Résumé
Atrial fibrillation and heart failure with reduced ejection fraction (HFrEF) are common sources of cardioembolism. While oral anticoagulation is strongly recommended for atrial fibrillation, there are marked variations in guideline recommendations for HFrEF due to uncertainty about net clinical benefit. This systematic review and meta-analysis evaluates the comparative association of oral anticoagulation with stroke and other cardiovascular risk in populations with atrial fibrillation or HFrEF in sinus rhythm and identify factors mediating different estimates of net clinical benefit. PubMed and Embase were searched from database inception to November 20, 2019 for randomized clinical trials comparing oral anticoagulation to control. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall and within atrial fibrillation and HFrEF trials. Differences in treatment effect were assessed by estimating I2 among all trials and testing the between-trial-population P-interaction. The primary outcome measure was all stroke. Secondary outcome measures were ischemic stroke, hemorrhagic stroke, mortality, myocardial infarction, and major hemorrhage. Twenty-one trials were eligible for inclusion, 15 (n=19 332) in atrial fibrillation (mean follow-up: 23.1 months), and 6 (n=9866) in HFrEF (mean follow-up: 23.9 months). There were differences in primary outcomes between trial populations, with all-cause mortality included for 95.2% of HFrEF trial population versus 0.38% for atrial fibrillation. Mortality was higher in controls groups of HFrEF populations (19.0% versus 9.6%) but rates of stroke lower (3.1% versus 7.0%) compared with atrial fibrillation. The association of oral anticoagulation with all stroke was consistent for atrial fibrillation (odds ratio, 0.51 [95% CI, 0.42–0.63]) and HFrEF (odds ratio, 0.61 [95% CI, 0.47–0.79]; I2=12.4%; P interaction=0.31). There were no statistically significant differences in the association of oral anticoagulation with cardiovascular events, mortality or bleeding between populations. The relative association of oral anticoagulation with stroke risk, and other cardiovascular outcomes, is similar for patients with atrial fibrillation and HFrEF. Differences in the primary outcomes employed by trials in HFrEF, compared with atrial fibrillation, may have contributed to differing conclusions of the relative efficacy of oral anticoagulation.
Sections du résumé
Background and Purpose
Atrial fibrillation and heart failure with reduced ejection fraction (HFrEF) are common sources of cardioembolism. While oral anticoagulation is strongly recommended for atrial fibrillation, there are marked variations in guideline recommendations for HFrEF due to uncertainty about net clinical benefit. This systematic review and meta-analysis evaluates the comparative association of oral anticoagulation with stroke and other cardiovascular risk in populations with atrial fibrillation or HFrEF in sinus rhythm and identify factors mediating different estimates of net clinical benefit.
Methods
PubMed and Embase were searched from database inception to November 20, 2019 for randomized clinical trials comparing oral anticoagulation to control. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall and within atrial fibrillation and HFrEF trials. Differences in treatment effect were assessed by estimating I2 among all trials and testing the between-trial-population P-interaction. The primary outcome measure was all stroke. Secondary outcome measures were ischemic stroke, hemorrhagic stroke, mortality, myocardial infarction, and major hemorrhage.
Results
Twenty-one trials were eligible for inclusion, 15 (n=19 332) in atrial fibrillation (mean follow-up: 23.1 months), and 6 (n=9866) in HFrEF (mean follow-up: 23.9 months). There were differences in primary outcomes between trial populations, with all-cause mortality included for 95.2% of HFrEF trial population versus 0.38% for atrial fibrillation. Mortality was higher in controls groups of HFrEF populations (19.0% versus 9.6%) but rates of stroke lower (3.1% versus 7.0%) compared with atrial fibrillation. The association of oral anticoagulation with all stroke was consistent for atrial fibrillation (odds ratio, 0.51 [95% CI, 0.42–0.63]) and HFrEF (odds ratio, 0.61 [95% CI, 0.47–0.79]; I2=12.4%; P interaction=0.31). There were no statistically significant differences in the association of oral anticoagulation with cardiovascular events, mortality or bleeding between populations.
Conclusions
The relative association of oral anticoagulation with stroke risk, and other cardiovascular outcomes, is similar for patients with atrial fibrillation and HFrEF. Differences in the primary outcomes employed by trials in HFrEF, compared with atrial fibrillation, may have contributed to differing conclusions of the relative efficacy of oral anticoagulation.
Identifiants
pubmed: 34281383
doi: 10.1161/STROKEAHA.120.033910
pmc: PMC8478106
mid: EMS128861
doi:
Substances chimiques
Anticoagulants
0
Types de publication
Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
3151-3162Subventions
Organisme : Wellcome Trust
ID : 203930
Pays : United Kingdom
Organisme : European Research Council
ID : 640580
Pays : International
Références
Lancet. 2007 Aug 11;370(9586):493-503
pubmed: 17693178
Eur J Heart Fail. 2006 Jun;8(4):428-32
pubmed: 16737850
J Am Coll Cardiol. 1991 Aug;18(2):349-55
pubmed: 1856403
Circulation. 2013 Oct 15;128(16):e240-327
pubmed: 23741058
Cochrane Database Syst Rev. 2019 Oct 3;10:ED000142
pubmed: 31643080
Eur Heart J. 2021 Feb 1;42(5):373-498
pubmed: 32860505
Am Heart J. 1992 Dec;124(6):1567-73
pubmed: 1462916
Syst Rev. 2016 Dec 5;5(1):210
pubmed: 27919275
N Engl J Med. 2012 May 17;366(20):1859-69
pubmed: 22551105
Stat Med. 2004 May 15;23(9):1351-75
pubmed: 15116347
Age Ageing. 2007 Mar;36(2):151-6
pubmed: 17175564
Can J Cardiol. 1997 Sep;13(9):811-5
pubmed: 9343029
Res Synth Methods. 2016 Mar;7(1):55-79
pubmed: 26332144
BMJ. 2005 Mar 12;330(7491):594-6
pubmed: 15761002
Ann Intern Med. 2009 Aug 18;151(4):264-9, W64
pubmed: 19622511
Can J Cardiol. 2018 Nov;34(11):1371-1392
pubmed: 30404743
Eur J Heart Fail. 2013 Jan;15(1):69-78
pubmed: 23143796
Lancet. 1989 Jan 28;1(8631):175-9
pubmed: 2563096
Am Heart J. 2004 Jul;148(1):157-64
pubmed: 15215806
Eur J Intern Med. 2006 Jan;17(1):48-52
pubmed: 16378886
J Card Fail. 2006 Feb;12(1):e1-2
pubmed: 16500560
Am Heart J. 2005 Apr;149(4):650-6
pubmed: 15990748
J Am Coll Cardiol. 2004 Oct 19;44(8):1557-66
pubmed: 15489085
Lancet. 1993 Nov 20;342(8882):1255-62
pubmed: 7901582
Eur Heart J. 2019 Nov 21;40(44):3593-3602
pubmed: 31461239
Ann Intern Med. 2007 Jun 19;146(12):857-67
pubmed: 17577005
Lancet. 1994 Mar 19;343(8899):687-91
pubmed: 7907677
N Engl J Med. 2011 Mar 3;364(9):806-17
pubmed: 21309657
BMJ. 2007 Apr 14;334(7597):786
pubmed: 17403713
N Engl J Med. 2018 Oct 4;379(14):1332-1342
pubmed: 30146935
N Engl J Med. 1992 Nov 12;327(20):1406-12
pubmed: 1406859
Blood. 2009 Jul 30;114(5):952-6
pubmed: 19439733
J Am Coll Cardiol. 2017 Aug 8;70(6):776-803
pubmed: 28461007
Circulation. 2019 Aug 13;140(7):529-537
pubmed: 31163978
Lancet. 2006 Jun 10;367(9526):1903-12
pubmed: 16765759
BMJ. 2019 Aug 28;366:l4898
pubmed: 31462531
Arch Intern Med. 1998 Jul 27;158(14):1513-21
pubmed: 9679792
Circulation. 1991 Aug;84(2):527-39
pubmed: 1860198
Eur Heart J. 2020 Jan 14;41(3):407-477
pubmed: 31504439
Heart. 2019 Sep;105(17):1325-1334
pubmed: 30962190
BMJ. 2010 Mar 30;340:c117
pubmed: 20354011
Cerebrovasc Dis. 2011;32(1):22-7
pubmed: 21576939
Circulation. 2009 Mar 31;119(12):1616-24
pubmed: 19289640
Chest. 2012 Feb;141(2 Suppl):7S-47S
pubmed: 22315257
BMJ. 1999 Oct 9;319(7215):958-64
pubmed: 10514159
Circulation. 2019 Jul 9;140(2):e125-e151
pubmed: 30686041