WSO - April 2023 - 392

1109149
WSO
International Journal of Stroke X(X)Li et al.
Systematic Review
Efficacy and safety of vitamin-K
antagonists and direct oral anticoagulants
for stroke prevention in patients with
heart failure and sinus rhythm: An
updated systematic review and metaanalysis
of randomized clinical trials
Weijia Li1 , Jiyoung Seo1, Damianos G Kokkinidis2,
Leonidas Palaiodimos1, Sanjana Nagraj1, Eleni Korompoki3
,
Haralambos Milionis4 , Wolfram Doehner5, Gregory Y. H. Lip6
and George Ntaios7
Abstract
Introduction: Heart failure (HF) is a major public health issue associated with significantly increased risk of stroke. It
remains uncertain whether oral anticoagulation (OAC) in patients with heart failure and sinus rhythm (HF-SR) could
improve prognosis.
Methods: We performed a systematic search of PubMed and Embase databases for randomized controlled clinical trials
assessing oral anticoagulants versus antiplatelets or placebo in patients with HF or ventricular dysfunction/cardiomyopathy
without clinical HF and SR. The outcomes assessed were stroke/systemic embolism, major bleeding, myocardial
infarction, all-cause mortality, and HF hospitalization.
Results: Seven trials of 15,794 patients were eligible for our analyses. The overall follow-up duration was 32,367 patientyears
corresponding to a mean follow-up of 2.05 years per patient. Four trials included patients treated with warfarin and
three included patients treated with rivaroxaban. OAC was associated with reduced rate of stroke or systemic embolism
compared to control (odds ratio (OR): 0.57, 95% confidence interval (CI): 0.44, 0.73, number needed to treat (NNT):
71.9) but higher rate of major bleeding (OR: 1.92, 95% CI: 1.47, 2.50, number needed to harm (NNH): 57.1). In the
subgroup analysis according to the type of OAC, rivaroxaban was associated with significantly reduced rate of stroke or
systemic embolism (1.24 vs 1.97 events per 100 patient-years, respectively, OR: 0.63, 95% CI: 0.45, 0.88, NNT: 82) and
higher risk of major bleeding (OR: 1.66, 95% CI: 1.26, 2.20) compared to antiplatelets or placebo. There was no significant
differences between groups for the outcomes of myocardial infarction, all-cause mortality, and HF hospitalization.
Conclusion: This analysis shows that any benefit of OAC for stroke prevention may be offset by an increased risk of major
bleeding in HF-SR patients. A well-designed randomized controlled trial of newer safer OACs is needed in this population.
1 Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY, USA
2 Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
3 Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital, Greece
4 Department of Internal Medicine, University of Ioannina, Ioannina, Greece
5 Berlin Institute of Health at Charité, BIH Center for Regenerative Therapies (BCRT), and Department of Cardiology (Virchow Klinikum) and
Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
6 Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
7 Department of Internal Medicine, Faculty of Health Sciences, University of Thessaly, Larissa, Greece
Corresponding author:
George Ntaios, Department of Internal Medicine, Faculty of Health Sciences, University of Thessaly, Larissa, 41110, Greece.
Email: gntaios@med.uth.gr Twitter: @Weijia_LiMED
Correction (March 2023) Article updated to correct the article type from Research to Systematic Review
International Journal of Stroke, 18(4)
International Journal of Stroke
2023, Vol. 18(4) 392 -399
© 2022 World Stroke Organization
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DOI: 10.1177/17474930221109149
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