Non-vitamin K Antagonist Oral Anticoagulants for Cardioversion in Atrial Fibrillation - An Updated Meta-analysis

Background Non-vitamin K oral anticoagulants are now proven alternatives to vitamin K antagonists for stroke prevention in atrial fibrillation. However, there are few data on the efficacy and safety of their use for cardioversion, in which the risk of thromboembolic events is heightened. Methods We performed a random-effects meta-analysis of patients undergoing both electrical and pharmacologic cardioversion for atrial fibrillation in the RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE AF-TIMI 48, X-VeRT, and ENSURE-AF trials. We assessed Mantel-Haenszel pooled estimates of risk ratios (RRs) and 95% confidence intervals (CIs) for stroke/systemic embolism and major bleeding at ≤42 days of follow-up. Results The analysis pooled 6148 patients in whom 6854 cardioversions for atrial fibrillation were performed. Compared with vitamin K antagonists, non-vitamin K antagonist oral anticoagulant therapy was associated with a similar risk of stroke/systemic embolism (RR, 0.82; 95% CI, 0.38-1.75) and major bleeding (RR, 0.98; 95% CI, 0.51-1.87). We found no significant statistical heterogeneity among studies (Cochrane Q P = .75, I2 = 0% for stroke/systemic embolism; P = .54; I2 = 0% for major bleeding). Conclusions The short-term incidence of thromboembolism and major bleeding after cardioversion on non-vitamin K antagonist oral anticoagulants was comparable to the incidence observed on dose-adjusted vitamin K antagonist therapy. Non-vitamin K antagonist oral anticoagulants are a reasonable alternative to vitamin K antagonists in patients undergoing cardioversion.