Comparative Efficacy and Safety of Direct Oral Anticoagulants Versus Warfarin in Cancer Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND

Limited data exist comparing direct oral anticoagulants (DOACs) with warfarin in patients with atrial fibrillation (AF) and cancer.

OBJECTIVES

This meta-analysis aimed to evaluate the comparative safety and efficacy of DOACs versus warfarin in AF patients with cancer.

METHODS

A comprehensive search of 5 electronic databases identified studies comparing DOACs with warfarin in this patient population. The primary outcomes assessed were ischemic stroke or systemic embolism, major hemorrhage, and mortality. Secondary outcomes included myocardial infarction, any hemorrhage, intracranial hemorrhage, and gastrointestinal hemorrhage. Analysis was conducted using RevMan 5.4, with odds ratios (OR) and 95% confidence intervals (CI) calculated.

RESULTS

Fourteen studies (3 randomized controlled trials, 11 cohort studies) were included. Patients with AF and cancer treated with DOACs had significantly lower odds of ischemic stroke/systemic embolism (OR 0.78; 95% CI 0.67-0.90, p = 0.001), major hemorrhage (OR 0.78; 95% CI 0.70-0.86, p < 0.00001), and mortality (OR 0.75; 95% CI 0.69-0.82, p < 0.00001) compared to warfarin. DOACs also showed significantly lower odds of myocardial infarction (OR 0.74; 95% CI 0.58-0.94, p < 0.01), intracranial hemorrhage (OR 0.74; 95% CI 0.68-0.81, p < 0.00001), and gastrointestinal hemorrhage (OR 0.82; 95% CI 0.69-0.98, p = 0.03). There was no significant difference in the overall risk of any hemorrhage (OR 0.94; 95% CI 0.81-1.10, p = 0.46).

CONCLUSIONS

DOACs demonstrated lower rates of ischemic stroke, systemic embolism, and major hemorrhage compared with warfarin in AF patients with cancer. Future research should focus on the relative efficacy of DOACs across cancer subtypes and stages.