Efficacy and Safety of New Oral Anticoagulants Versus Warfarin in the Resolution of Atrial Fibrillation with Left Atrial/Left Atrial Appendage Thrombus: A Systematic Review and Meta-Analysis

Overview

Journal Rev Cardiovasc Med

Date 2025 Jan 27

PMID 39867171

Authors

Guan-Lian Mo

Jing Wen

Yu-Yu Ye

Yong-Qi Lu

Tian-Ming Gan

Ying-Jie Yang

Jin-Yi Li

Affiliations

Soon will be listed here.

Abstract

Background: To compare the efficacy and safety of novel oral anticoagulants (NOACs) and vitamin K antagonists (VKAs) in nonvalvular atrial fibrillation (NVAF) patients with left atrial/left atrial thrombosis through a systematic review and meta-analysis.

Methods: The CBM (China Biology Medicine disc), CNKI (China National Knowledge Infrastructure), VIP (Chinese Technology Periodical Database), Wanfang, PubMed, Embase, Cochrane Library, and Web of Science databases were searched for relevant studies from their inception to June 30, 2022.

Results: Twelve articles (eight cohort studies and four randomized controlled trials) involving 982 patients were included. Meta-analysis showed that NOACs had a significantly higher thrombolysis rate than VKAs (78.0% vs. 63.5%, odds ratio (OR) = 2.32, 95% confidence interval (CI) 1.71 to 3.15, < 0.0001). Subgroup analysis revealed rivaroxaban to be more effective than VKAs, whereas there was no significant difference between dabigatran and apixaban. There were no significant differences in embolic events, bleeding, or all-cause mortality. Thrombus resolution analysis showed higher left ventricular end-diastolic diameter and smaller left atrial diameter in the effective group than in the ineffective group.

Conclusions: NOACs are more effective in thrombolysis than VKAs in NVAF patients with left atrial thrombosis, and there is no increased risk of adverse events compared with VKAs.

References

Mitamura H, Nagai T, Watanabe A, Takatsuki S, Okumura K . Left atrial thrombus formation and resolution during dabigatran therapy: A Japanese Heart Rhythm Society report. J Arrhythm. 2015; 31(4):226-31. PMC: 4556082. DOI: 10.1016/j.joa.2014.12.010. View

Zhao Y, Zhang P, Xu Q, Yu L, Yu Y, Li Y . Relationship between left atrial appendage morphology and thrombus formation in patients with atrial fibrillation. Int J Cardiol. 2015; 188:86-8. DOI: 10.1016/j.ijcard.2015.04.033. View

Eikelboom J, Wallentin L, Connolly S, Ezekowitz M, Healey J, Oldgren J . Risk of bleeding with 2 doses of dabigatran compared with warfarin in older and younger patients with atrial fibrillation: an analysis of the randomized evaluation of long-term anticoagulant therapy (RE-LY) trial. Circulation. 2011; 123(21):2363-72. DOI: 10.1161/CIRCULATIONAHA.110.004747. View

Murtaza G, Yarlagadda B, Akella K, Della Rocca D, Gopinathannair R, Natale A . Role of the Left Atrial Appendage in Systemic Homeostasis, Arrhythmogenesis, and Beyond. Card Electrophysiol Clin. 2020; 12(1):21-28. DOI: 10.1016/j.ccep.2019.11.004. View

Hussain A, Wang N . Meta-analyses for oral anticoagulants and left atrial appendage thrombus resolution in nonvalvular atrial fibrillation: Piecing the puzzle together. J Cardiovasc Electrophysiol. 2020; 31(8):2261-2262. DOI: 10.1111/jce.14568. View

Chowdhury D, Gurvitz M, Marelli A, Anderson J, Baker-Smith C, Diab K . Development of Quality Metrics in Ambulatory Pediatric Cardiology. J Am Coll Cardiol. 2017; 69(5):541-555. DOI: 10.1016/j.jacc.2016.11.043. View

Granger C, Alexander J, McMurray J, Lopes R, Hylek E, Hanna M . Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011; 365(11):981-92. DOI: 10.1056/NEJMoa1107039. View

Hautmann M, Zacher M, Fuchs S, Perez C, Ahmidou A, Kerber S . Left atrial appendage thrombus formation, potential of resolution and association with prognosis in a large real-world cohort. Sci Rep. 2023; 13(1):889. PMC: 9845308. DOI: 10.1038/s41598-023-27622-3. View

Hijazi Z, Hohnloser S, Andersson U, Alexander J, Hanna M, Keltai M . Efficacy and Safety of Apixaban Compared With Warfarin in Patients With Atrial Fibrillation in Relation to Renal Function Over Time: Insights From the ARISTOTLE Randomized Clinical Trial. JAMA Cardiol. 2016; 1(4):451-60. DOI: 10.1001/jamacardio.2016.1170. View

Nelles D, Lambers M, Schafigh M, Morais P, Schueler R, Vij V . Clinical outcomes and thrombus resolution in patients with solid left atrial appendage thrombi: results of a single-center real-world registry. Clin Res Cardiol. 2020; 110(1):72-83. DOI: 10.1007/s00392-020-01651-8. View

10.

Lau W, Torre C, Man K, Morgan Stewart H, Seager S, Van Zandt M . Comparative Effectiveness and Safety Between Apixaban, Dabigatran, Edoxaban, and Rivaroxaban Among Patients With Atrial Fibrillation : A Multinational Population-Based Cohort Study. Ann Intern Med. 2022; 175(11):1515-1524. DOI: 10.7326/M22-0511. View

11.

Weitz J, Connolly S, Patel I, Salazar D, Rohatagi S, Mendell J . Randomised, parallel-group, multicentre, multinational phase 2 study comparing edoxaban, an oral factor Xa inhibitor, with warfarin for stroke prevention in patients with atrial fibrillation. Thromb Haemost. 2010; 104(3):633-41. DOI: 10.1160/TH10-01-0066. View

12.

Harada M, Koshikawa M, Motoike Y, Ichikawa T, Sugimoto K, Watanabe E . Left Atrial Appendage Thrombus Prior to Atrial Fibrillation Ablation in the Era of Direct Oral Anticoagulants. Circ J. 2018; 82(11):2715-2721. DOI: 10.1253/circj.CJ-18-0398. View

13.

Xing X, Liu N, Han Y, Zhou W, Liang M, Wang Z . Anticoagulation efficacy of dabigatran etexilate for left atrial appendage thrombus in patients with atrial fibrillation by transthoracic and transesophageal echocardiography. Medicine (Baltimore). 2018; 97(26):e11117. PMC: 6039616. DOI: 10.1097/MD.0000000000011117. View

14.

Wong C, Chan P, Lam C, Kwok O, Lam Y, Siu C . WATCHMAN device-related thrombus successfully treated with apixaban: A case report. Medicine (Baltimore). 2018; 96(47):e8693. PMC: 5708950. DOI: 10.1097/MD.0000000000008693. View

15.

Zylla M, Pohlmeier M, Hess A, Mereles D, Kieser M, Bruckner T . Prevalence of intracardiac thrombi under phenprocoumon, direct oral anticoagulants (dabigatran and rivaroxaban), and bridging therapy in patients with atrial fibrillation and flutter. Am J Cardiol. 2015; 115(5):635-40. DOI: 10.1016/j.amjcard.2014.12.016. View

16.

Olesen J, Lip G, Lindhardsen J, Lane D, Ahlehoff O, Hansen M . Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: A net clinical benefit analysis using a 'real world' nationwide cohort study. Thromb Haemost. 2011; 106(4):739-49. DOI: 10.1160/TH11-05-0364. View

17.

Muric M, Nikolic M, Todorovic A, Jakovljevic V, Vucicevic K . Comparative Cardioprotective Effectiveness: NOACs vs. Nattokinase-Bridging Basic Research to Clinical Findings. Biomolecules. 2024; 14(8). PMC: 11352257. DOI: 10.3390/biom14080956. View

18.

Lip G, Hammerstingl C, Marin F, Cappato R, Meng I, Kirsch B . Left atrial thrombus resolution in atrial fibrillation or flutter: Results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J. 2016; 178:126-34. DOI: 10.1016/j.ahj.2016.05.007. View

19.

Hart R, Pearce L, Aguilar M . Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007; 146(12):857-67. DOI: 10.7326/0003-4819-146-12-200706190-00007. View