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Review
. 2022 Sep 4;14(9):e28763.
doi: 10.7759/cureus.28763. eCollection 2022 Sep.

Comparison of Direct Oral Anticoagulants and Warfarin in the Prevention of Stroke in Patients With Valvular Heart Disease: A Meta-Analysis

Saima Batool  1 , Sandipkumar S Chaudhari  2   3 , Tanveer Ahamad Shaik  4 , Sandesh Dhakal  5 , Zubair Ahmad Ganaie  6 , Muhammad Abu Zar Ghaffari  7 , Faraz Saleem  7 , Areeba Khan  8
Affiliations
Review

Comparison of Direct Oral Anticoagulants and Warfarin in the Prevention of Stroke in Patients With Valvular Heart Disease: A Meta-Analysis

Saima Batool et al. Cureus. .

Abstract

Warfarin is the standard of care, and direct oral anticoagulants (DOACs) are a group of newer drugs to prevent stroke in patients with valvular heart disease. The aim of this meta-analysis is to compare the efficacy and safety of DOACs and warfarin in the prevention of stroke in patients with valvular heart disease (VHD). The current meta-analysis was conducted using the standards developed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendation. The databases from the Cochrane library, PubMed, and Excerpta Medica database (EMBASE) were used to search for relevant articles without placing restrictions on the year of publication. Outcomes assessed in the current meta-analysis included a number of patients with stroke or systemic embolism, patients having myocardial infarction during the study period, patients with major bleeding events, and patients who died due to any reason. Overall, five studies were included in the current meta-analysis. Direct oral anticoagulants were associated with a lower risk of stroke or systemic embolism in patients with VHD (relative risk (RR): 0.75, 95% confidence interval (C)I: 0.60 to 0.94). The risk of major bleeding events is 31% lower in patients receiving DOAC compared to patients receiving warfarin (RR: 0.69, 95% CI: 0.58 to 0.83). No significant difference was found between the two groups in terms of all-cause mortality and myocardial infarction. The current meta-analysis shows that DOACs were associated with a lower risk of stroke or systemic embolism as compared to warfarin in patients with VHD. Besides this, the risk of major bleeding events was also lower in patients receiving DOACs compared to patients receiving warfarin. No significant differences were reported in terms of myocardial infarction and all-cause mortality between the two groups.

Keywords: direct oral anticoagulants; meta-analysis; stroke; valvular heart disease; warfarin.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. PRISMA flowchart of the selection of studies
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Figure 2
Figure 2. Risk of bias assessment
Figure 3
Figure 3. Forest plot of comparison of DOACs and warfarin on the risk of stroke in patients with VHD
Sources: References [11-15] DOACs: Direct oral anticoagulants, VHD: Valvular heart disease, CI: Confidence interval
Figure 4
Figure 4. Forest plot of comparison of DOACs and warfarin on the risk of myocardial infarction in patients with VHD
Sources: References [11-13] DOACs: Direct oral anticoagulants, VHD: Valvular heart disease, CI: Confidence interval
Figure 5
Figure 5. Forest plot of comparison of DOACs and warfarin on the risk of major bleeding events in patients with VHD
Sources: References [11-15] DOACs: Direct oral anticoagulants, VHD: Valvular heart disease, CI: Confidence interval
Figure 6
Figure 6. Forest plot of comparison of DOACs and warfarin on the risk of all-cause mortality among patients with VHD
Sources: References [11-15] DOACs: Direct oral anticoagulants, VHD: Valvular heart disease, CI: Confidence interval
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