The Efficacy of Non–Vitamin K Antagonist Oral Anticoagulants in the Prevention of Left Atrial Thrombus in Patients With Atrial Fibrillation Compared With Vitamin K Antagonists: A Meta-Analysis

Authors

  • Jun Liu, MD Department of Geratology, Handan Central Hospital, Hebei, Handan, China
  • Yi-Ping Wu, MD Department of Neurology, Handan Central Hospital, Hebei, Handan, China
  • Shu-Rui Li, MD Department of Geratology, Handan Central Hospital, Hebei, Handan, China
  • Li-Hong Song, MD Imaging Department, Handan Central Hospital, Hebei, Handan, China; 4Department of Orthopedics, Handan Central Hospital, Hebei, Handan China
  • Cheng-Dong Hu, MD Department of Orthopedics, Handan Central Hospital, Hebei, Handan China

DOI:

https://doi.org/10.1532/hsf.3203

Keywords:

Non–vitamin K antagonist oral anticoagulants, Atrial fibrillation, Vitamin K antagonists, Transesophageal echocardiography, Left atrial appendage thrombus

Abstract

Background: There is still a paucity of data on the efficacy of non–vitamin K antagonist oral anticoagulants (NOACs) in the prevention of left atrial thrombus (LAT) formation before cardioversion or catheter ablation. To assess the efficacy of NOACs in the prevention of LAT in patients with non-valvular atrial fibrillation (NVAF) compared with vitamin K antagonists (VKAs), we conducted a meta-analysis.

Methods: We searched PubMed, Embase, and the Cochrane Library databases. For meta-analysis, dichotomous variables were analyzed by using the odds ratios (OR) computed using the Mantel Haenszel method (random models). All results were reported with 95% confidence intervals (CI).

Results: A total of 13 studies (one randomized controlled investigation and 12 observational studies) were included in the meta-analysis. There was no statistically significant difference between the NOACs and VKAs groups with respect to the odds of LAT/LAAT formations (OR 0.79; 95% CI: 0.52-1.21; P = .29; (I2 = 14%).

Conclusions: NOACs were as effective as VKAs in the prevention of LAT/LAAT formation in patients with NVAF. Though patients on NOACs therapy showed a lower incidence of LAT/LAAT formation compared with VKAs, it was not significant (P = .29).

References

Barysienė J, Žebrauskaitė A, Petrikonytė D, Marinskis G, Aidietienė S, Aidietis A. 2017. Findings of transoesophageal echocardiogram in appropriately anticoagulated patients with persistent atrial fibrillation prior to planned cardioversion. BMC Cardiovasc Disord. 17(1):67.

Bertaglia E, Anselmino M, Zorzi A, et al. 2017. NOACs and atrial fibrillation: Incidence and predictors of left atrial thrombus in the real world. Int J Cardiol. 249:179-183.

Di Minno MN, Ambrosino P, Dello Russo A, Casella M, Tremoli E, Tondo C. 2016. Prevalence of left atrial thrombus in patients with non-valvular atrial fibrillation. A systematic review and meta-analysis of the literature. Thromb Haemost. 115(3):663-677.

Essien UR, Magnani JW, Chen N, Gellad WF, Fine MJ, Hernandez I. 2020. Race/Ethnicity and Sex-Related Differences in Direct Oral Anticoagulant Initiation in Newly Diagnosed Atrial Fibrillation: A Retrospective Study of Medicare Data. J Natl Med Assoc. 112(1):103-108.

Frenkel D, D'Amato SA, Al-Kazaz M, et al. 2016. Prevalence of Left Atrial Thrombus Detection by Transesophageal Echocardiography: A Comparison of Continuous Non-Vitamin K Antagonist Oral Anticoagulant Versus Warfarin Therapy in Patients Undergoing Catheter Ablation for Atrial Fibrillation. JACC Clin Electrophysiol. 2(3):295-303.

Goette A, Merino JL, Ezekowitz MD, et al. 2016. Edoxaban versus enoxaparin-warfarin in patients undergoing cardioversion of atrial fibrillation (ENSURE-AF): a randomised, open-label, phase 3b trial [published correction appears in Lancet. 2016 Oct 22;388(10055):1984]. Lancet. 388(10055):1995-2003.

Gunawardene MA, Dickow J, Schaeffer BN, et al. 2017. Risk stratification of patients with left atrial appendage thrombus prior to catheter ablation of atrial fibrillation: An approach towards an individualized use of transesophageal echocardiography. J Cardiovasc Electrophysiol. 28(10):1127-1136.

Hahn RT, Abraham T, Adams MS, et al. 2013. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 26(9):921-964.

Higgins JPT, Green S, editors. 2011. Cochrane handbook for systematic reviews of interventions. New York: Wiley.

Jackson LR 2nd, Kim S, Shrader P, et al. 2018. Early therapeutic persistence on dabigatran versus warfarin therapy in patients with atrial fibrillation: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry. J Thromb Thrombolysis. 46(4):435-439.

Jackson LR 2nd, Peterson ED, Okeagu E, Thomas K. 2015. Review of race/ethnicity in non-vitamin K antagonist oral anticoagulants clinical trials. J Thromb Thrombolysis. 39(2):222-227.

January CT, Wann LS, Alpert JS, et al. 2014. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society [published correction appears in Circulation. 2014 Dec 2;130(23):e272-4]. Circulation. 130(23):e199-e267.

January CT, Wann LS, Calkins H, et al. 2019. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons [published correction appears in Circulation. 2019 Aug 6;140(6):e285]. Circulation. 140(2):e125-e151.

Kawabata M, Goya M, Sasaki T, et al. 2017. Left Atrial Appendage Thrombi Formation in Japanese Non-Valvular Atrial Fibrillation Patients During Anticoagulation Therapy - Warfarin vs. Direct Oral Anticoagulants. Circ J. 81(5):645-651.

Kim JS, She F, Jongnarangsin K, et al. 2013. Dabigatran vs warfarin for radiofrequency catheter ablation of atrial fibrillation. Heart Rhythm. 10(4):483-489.

Kim YG, Choi JI, Kim MN, et al. 2018. Non-vitamin K antagonist oral anticoagulants versus warfarin for the prevention of spontaneous echo-contrast and thrombus in patients with atrial fibrillation or flutter undergoing cardioversion: A transesophageal echocardiography study. PLoS One. 13(1):e0191648.

Klein AL, Grimm RA, Murray RD, et al. 2001. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med. 344(19):1411-1420.

Maddox W, Kay GN, Yamada T, et al. 2013. Dabigatran versus warfarin therapy for uninterrupted oral anticoagulation during atrial fibrillation ablation. J Cardiovasc Electrophysiol. 24(8):861-865.

Manning WJ, Weintraub RM, Waksmonski CA, et al. 1995. Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study. Ann Intern Med. 123(11):817-822.

Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. 2009. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 151(4):264-W64.

Nagarakanti R, Ezekowitz MD, Oldgren J, et al. 2011. Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation. 123(2):131-136.

Patti G, Pengo V, Marcucci R, et al. 2017. The left atrial appendage: from embryology to prevention of thromboembolism. Eur Heart J. 38(12):877-887.

Reers S, Agdirlioglu T, Kellner M, et al. 2016. Incidence of left atrial abnormalities under treatment with dabigatran, rivaroxaban, and vitamin K antagonists. Eur J Med Res. 21(1):41.

Reers S, Karanatsios G, Borowski M, Kellner M, Reppel M, Waltenberger J. 2018. Frequency of atrial thrombus formation in patients with atrial fibrillation under treatment with non-vitamin K oral anticoagulants in comparison to vitamin K antagonists: a systematic review and meta-analysis. Eur J Med Res. 23(1):49.

Schaeffer B, Rüden L, Salzbrunn T, et al. 2018. Incidence of intracardiac thrombus formation prior to electrical cardioversion in respect to the mode of oral anticoagulation. J Cardiovasc Electrophysiol. 29(4):537-547.

Schotten U, Verheule S, Kirchhof P, Goette A. 2011. Pathophysiological mechanisms of atrial fibrillation: a translational appraisal [published correction appears in Physiol Rev. 2011 Oct;91(4):1533]. Physiol Rev. 91(1):265-325.

Somani R, Mohajer K, Haley C, et al. 2014. The peri-procedural use of dabigatran in patients undergoing left atrial ablation for atrial fibrillation. Cardiovasc Ther. 32(5):198-201.

Telles-Garcia N, Dahal K, Kocherla C, Lip GYH, Reddy P, Dominic P. 2018. Non-vitamin K antagonists oral anticoagulants are as safe and effective as warfarin for cardioversion of atrial fibrillation: A systematic review and meta-analysis. Int J Cardiol. 268:143-148.

Ţînţ D, Petriş AO, Pop I, Melnic R, Ignat AM, Rogozea LM. 2017. Vitamin K Antagonists Versus Novel Oral Anticoagulants for Elective Electrical Cardioversion of Atrial Fibrillation. Am J Ther. 24(5):e553-e558.

Wallace TW, Atwater BD, Daubert JP, et al. 2010. Prevalence and clinical characteristics associated with left atrial appendage thrombus in fully anticoagulated patients undergoing catheter-directed atrial fibrillation ablation. J Cardiovasc Electrophysiol. 21(8):849-852.

Wang NC, Sather MD, Hussain A, et al. 2018. Oral anticoagulation and left atrial thrombi resolution in nonrheumatic atrial fibrillation or flutter: A systematic review and meta-analysis. Pacing Clin Electrophysiol. 41(7):767-774.

Wyrembak J, Campbell KB, Steinberg BA, et al. 2017. Incidence and Predictors of Left Atrial Appendage Thrombus in Patients Treated With Nonvitamin K Oral Anticoagulants Versus Warfarin Before Catheter Ablation for Atrial Fibrillation. Am J Cardiol. 119(7):1017-1022.

Yang J, Zhang X, Wang XY, Zhang C, Chen SZ, Hu SJ. 2019. Comparison of transesophageal echocardiography findings after different anticoagulation strategies in patients with atrial fibrillation: a systematic review and meta-analysis. BMC Cardiovasc Disord. 19(1):261.

Zhou J, Kang ZF,Liu LL, et al. 2019. Predicting Value of Growth Differentiation Factor 15 and Its Correlations With Atrial Fibrillation. The Heart Surgery Forum 23: E452-E460.

Published

2020-10-12

How to Cite

Liu, J., Wu, Y., Li, S., Song, L., & Hu, C. (2020). The Efficacy of Non–Vitamin K Antagonist Oral Anticoagulants in the Prevention of Left Atrial Thrombus in Patients With Atrial Fibrillation Compared With Vitamin K Antagonists: A Meta-Analysis. The Heart Surgery Forum, 23(6), E733-E739. https://doi.org/10.1532/hsf.3203

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