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Review
. 2024 Oct 25;16(10):e72351.
doi: 10.7759/cureus.72351. eCollection 2024 Oct.

Comparison of Apixaban, Rivaroxaban, Dabigatran, and Vitamin K Antagonists in Patients With Atrial Fibrillation and Liver Disease: A Network Meta-Analysis

Sanam Shaikh  1 , Gautham Varun Krishna Mohan  2 , Bansari Patel  3 , Sindhuja Sompalli  4 , Ihtisham Habib  5 , Sandipkumar S Chaudhari  6   7 , Calvin R Wei  8 , Areeba Khan  9
Affiliations
Review

Comparison of Apixaban, Rivaroxaban, Dabigatran, and Vitamin K Antagonists in Patients With Atrial Fibrillation and Liver Disease: A Network Meta-Analysis

Sanam Shaikh et al. Cureus. .

Abstract

Atrial fibrillation (AF) patients with liver disease present unique challenges in anticoagulation management due to increased risks of both thromboembolism and bleeding. This network meta-analysis aimed to compare the efficacy and safety of direct oral anticoagulants (DOACs), apixaban, rivaroxaban, and dabigatran, with vitamin K antagonists (VKAs) in this specific patient population. We conducted a comprehensive literature search across multiple databases, identifying seven studies (six observational and one randomized controlled trial) that met our inclusion criteria. The primary outcomes were the risk of stroke or systemic embolism (SE) and bleeding events. Our analysis revealed that all three DOACs demonstrated superior efficacy and safety profiles compared to VKAs. Apixaban showed the most favorable outcomes, with the highest probability of being the most effective in preventing both stroke/SE (RR: 0.51, 95% CI: 0.38-0.67) and bleeding events (RR: 0.54, 95% CI: 0.43-0.69). Rivaroxaban and dabigatran also significantly reduced the risk of these outcomes compared to VKAs but to a lesser extent than apixaban. Notably, rivaroxaban was associated with a slightly increased bleeding risk compared to apixaban (RR: 0.76, 95% CI: 0.58-0.99). The consistency of our network model was confirmed through both global and local tests. While these findings provide valuable guidance for clinicians, the study's limitations, including the predominance of observational data, highlight the need for large-scale randomized controlled trials. Future research should focus on clearly defined anticoagulant dosing regimens and comprehensive assessments of cirrhosis status to further optimize anticoagulation strategies in AF patients with liver disease.

Keywords: apixaban; atrial fibrillation; dabigatran; liver disease; rivaroxaban.

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Conflict of interest statement

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. PRISMA flowchart of study selection
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; DOAC: Direct oral anticoagulant
Figure 2
Figure 2. Comparison of risk of stroke or systemic embolism between different groups
VKA: Vitamin K antagonists; RR: Risk ratio; CI: Confidence interval Adapted from [13,15-18]
Figure 3
Figure 3. Heat plot comparing the risk of stroke or systemic embolism
All values presented as RR (95% CI) VKA: Vitamin K antagonists; RR: Risk ratio; CI: Confidence interval Adapted from [13,15-18]
Figure 4
Figure 4. Comparison of the risk of bleeding events between different groups
VKA: Vitamin K antagonists; RR: Risk ratio; CI: Confidence interval Adapted from [12-17]
Figure 5
Figure 5. Heath plot comparing the risk of bleeding events
All values presented as RR (95% CI) VKA: Vitamin K antagonists; RR: Risk ratio; CI: Confidence interval Adapted from [12-17]
See this image and copyright information in PMC

References

    1. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Benjamin EJ, Muntner P, Alonso A, et al. Circulation. 2019;139:0. - PubMed
    1. Impact of proteinuria and glomerular filtration rate on risk of thromboembolism in atrial fibrillation: the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study. Go AS, Fang MC, Udaltsova N, Chang Y, Pomernacki NK, Borowsky L, Singer DE. Circulation. 2009;119:1363–1369. - PMC - PubMed
    1. Anticoagulation in atrial fibrillation cardioversion: what is crucial to take into account. Lucà F, Giubilato S, Di Fusco SA, et al. J Clin Med. 2021;10:3212. - PMC - PubMed
    1. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Kirchhof P, Benussi S, Kotecha D, et al. Eur J Cardiothorac Surg. 2016;50:0. - PubMed
    1. Direct oral anticoagulants: new drugs and new concepts. Levy JH, Spyropoulos AC, Samama CM, Douketis J. JACC Cardiovasc Interv. 2014;7:1333–1351. - PubMed

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