Superiority of Direct Oral Anticoagulants over Vitamin K Antagonists in Oncological Patients with Atrial Fibrillation: Analysis of Efficacy and Safety Outcomes.

Background and aim . Cancer and atrial fibrillation (AF) may be associated, and anticoagulation, either with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), is necessary to prevent thromboembolic events by reducing the risk of bleeding. The log incidence rate ratio (IRR) and 95% confidence interval were used as index statistics. Higgin's I 2 test was adopted to assess statistical inconsistencies by considering interstudy variations, defined by values ranging from 0 to 100%. I 2 values of less than 40% are associated with very low heterogeneity among the studies; values between 40% and 75% indicate moderate heterogeneity, and those greater than 75% suggest severe heterogeneity. The aim of this meta-analysis was to compare the safety and efficacy of VKAs and DOACs in oncologic patients with AF. Methods . A meta-analysis was conducted comparing VKAs to DOACs in terms of thromboembolic events and bleeding. A meta-regression was conducted to investigate the differences in efficacy and safety between four different DOACs. Moreover, a sub-analysis on active-cancer-only patients was conducted. Results . A total of eight papers were included. The log incidence rate ratio (IRR) for thromboembolic events between the two groups was -0.69 ( p < 0.005). The meta-regression did not reveal significant differences between the types of DOACs ( p > 0.9). The Log IRR was -0.38 ( p = 0.008) for ischemic stroke, -0.43 ( p = 0.02) for myocardial infarction, -0.39 ( p = 0.45) for arterial embolism, and -1.04 ( p = 0.003) for venous thromboembolism. The log IRR for bleeding events was -0.43 ( p < 0.005), and the meta-regression revealed no statistical difference ( p = 0.7). The log IRR of hemorrhagic stroke, major bleeding, and clinically relevant non-major bleeding between the VKA and DOAC groups was -0.51 ( p < 0.0001), -0.45 ( p = 0.03), and 0.0045 ( p = 0.97), respectively. Similar results were found in active-cancer patients for all the endpoints except for clinically-relevant non-major bleedings. Conclusions . DOACs showed better efficacy and safety outcomes than VKAs. No difference was found between types of DOACs.