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Safety of Direct Oral Anticoagulants Compared to Warfarin for Atrial Fibrillation after Cardiac Surgery: A Systematic Review and Meta-Analysis

      The evidence for use of direct oral anticoagulants (DOACs) in the management of post-operative cardiac surgery atrial fibrillation is limited and mostly founded on clinical trials that excluded this patient population. We performed a systematic review and meta-analysis of clinical trials and observational studies to evaluate the hypothesis that DOACs are safe compared to warfarin for the anticoagulation of patients with post-operative cardiac surgery atrial fibrillation. We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and the Cochrane Library for clinical trials and observational studies comparing DOAC with warfarin in patients ≥18 years old who had post-cardiac surgery atrial fibrillation. Primary outcomes included stroke, systemic embolization, bleeding, and mortality. We performed a random-effects meta-analysis of all outcomes. The meta-analysis for the primary outcomes showed significantly lower risk of stroke with DOAC use (6 studies, 7143 patients, RR 0.64; 95% CI 0.50–0.81, I2: 0.0%) compared to warfarin, a trend towards lower risk of systemic embolization (4 studies, 7289 patients, RR 0.64, 95% CI 0.41–1.01, I2: 31.99%) and similar risks of bleeding (14 studies, 10182 patients, RR 0.91; 95% CI 0.74–1.10, I2: 26.6%) and mortality (12 studies, 9843 patients, relative risk [RR] 1.01; 95% CI 0.74–1.37, I2: 26.5%). Current evidence suggests that DOACs, compared to warfarin, in the management of atrial fibrillation after cardiac surgery is associated with lower risk of stroke and a strong trend for lower risk of systemic embolization, and no evidence of increased risk for hospital readmission, bleeding and mortality.

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      Linked Article

      • Commentary: Considering Treating Postoperative Atrial Fibrillation With Direct Oral Anticoagulants
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 3
        • Preview
          Postoperative atrial fibrillation (POAF) signifies often arrhythmia with ineffective blood circulation, which increases the risk of platelet adherence and thrombogenicity causing emboli. A pragmatic solution is to prescribe warfarin, though it requires constant laboratory monitoring. Direct oral anticoagulants (DOACs) enable a uniform dosing, though there is no evident means to control reversal of the anticoagulation effect.
        • Full-Text
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      • Commentary: Moving the Dial on DOAC use Early After Cardiac Surgery
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 3
        • Preview
          Atrial fibrillation remains an unsolved complication after cardiac surgery with published rates in the 20-50%.1,2 As outlined in a recent STS database analysis,3 over 60% of US surgeons still use warfarin rather than switching to direct oral anticoagulants (DOACs) for stroke prophylaxis in this clinical scenario. This trend persists despite the limitations associated with warfarin use, including prolonged and often turbulent early titration in new patients, dietary restrictions, strict monitoring requirements and extensive medication interactions.
        • Full-Text
        • PDF