Afib: NOACs best vitamin K antagonists in early-stage CKD

  • Ha JT & al.
  • Ann Intern Med
  • 16 Jul 2019

  • International Clinical Digest
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Takeaway

  • For Afib with early-stage chronic kidney disease (CKD), nonvitamin K oral anticoagulants (NOACs) offer a superior benefit-risk profile vs vitamin K antagonists (VKAs).

Why this matters

  • The authors caution that evidence is insufficient to extrapolate these findings to patients with advanced CKD or end-stage renal disease (ESRD).

Study design

  • Meta-analysis of 45 randomized controlled trials (n=34,082) of NOACs and VKAs in Afib (11 trials), venous thromboembolism (VTE, 11 trials), thromboprophylaxis (6 trials), prophylaxis of dialysis access thrombosis (8 trials), and non-Afib cardiovascular disease (9 trials).
  • Funding: None.    

Key results

  • High-certainty evidence supported high-dose NOACs over VKAs for reducing risk for stroke or systemic embolism in Afib and CKD:
    • Risk ratio (RR), 0.79 (95% CI, 0.66-0.93).
  • Moderate-certainty evidence supported high-dose NOACs over VKAs in CKD for preventing (RRs; 95% CIs):
    • Hemorrhagic stroke: 0.48 (0.30-0.76);
    • Intracranial hemorrhage: 0.49 (0.30-0.80); and
    • All-cause death: 0.88 (0.78-0.99).
  • Advantage of NOACs vs VKAs on recurrent VTE or VTE-related death failed to reach statistical significance: RR, 0.72 (95% CI, 0.44-1.17).
  • High-dose NOACs failed to show significant advantage over VKAs for reducing the risk for major bleeding: RR, 0.75 (95% CI, 0.56-1.01).

Limitations

  • Subgroup analysis of large trials.
  • None of 8 trials involving ESRD evaluated NOACs.