Effectiveness and safety of dabigatran compared to vitamin K antagonists in patients with atrial fibrillation: a systematic review and metanalysis.

Abstract Purpose : To assess the comparative effectiveness and safety of dabigatran ‒globally and stratified by dose (110 or 150 mg b.i.d.) compared to vitamin K antagonists (VKA) in patients with non-valvular atrial fibrillation (NVAF) from “real world” studies. Methods : A systematic review was performed according to Cochrane methodological standards. The results were reported according to the PRISMA statement. The ROBINS-I tool was used to assess risk of bias. Results: A total of 25 studies, corresponding to 27 articles involving 771.468 participants (490.082 exposed to VKA and 281.386 to dabigatran) were eligible for this review. Dabigatran reduced the risk of ischemic stroke compared to VKA, particularly dabigatran 150 mg, with a 15% risk reduction (HR 0.85, 95%CI 0.74-0.98). Globally, dabigatran reduced the risk of all-cause mortality compared to VKA (HR 0.75, 95%CI 0.67-0.85), with a greater effect observed with dabigatran 150 mg (HR 0.66, 95%CI 0.58-0.74). There was a trend towards a lower risk of myocardial infarction with dabigatran 150 mg (HR 0.86, 95%CI 0.71-1.04). Regarding the primary safety outcomes, dabigatran (either at a dose of 150 mg or 110 mg) reduced the risk of major bleeding compared to VKA (HR 0.74, 95%CI 0.66-0.83), as well as the risk of intracranial bleeding (HR 0.45, 95%CI 0.39-0.52) and fatal bleeding (HR 0.76, 95%CI 0.60-0.95), but with a non-significant trend towards a higher gastrointestinal bleeding risk (HR 1.08, 95%CI 0.99 to 1.18). Conclusion : Dabigatran has a favourable impact in effectiveness and safety outcomes compared to VKA in real-world populations.