P130 - SAFETY AND EFFICACY OF DIRECT ORAL ANTICOAGULANTS VERSUS VITAMIN K ANTAGONISTS IN PATIENTS WITH FRAILTY AND ATRIAL FIBRILLATION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background: Patients with frailty and atrial fibrillation (AF) are at an increased risk of both ischemic stroke and bleeding, posing a unique challenge for stroke prevention. This systematic review and meta-analysis aimed to compare the effectiveness and safety of individual direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in frail patients with AF.

METHODS AND RESULTS: We systematically searched PubMed, Embase, and CENTRAL for studies published between January 1, 2009, and July 2, 2024, that compared individual DOACs to VKAs for stroke prevention in frail patients with AF. Outcomes of interest were stroke/systemic embolism and major bleeding. Frailty was assessed using various validated tools, including the Clinical Frailty Scale, Frailty Index, and Hospital Frailty Risk Score. Odds ratios (ORs) were pooled using a random-effects model.
Of 881 articles identified, 6 studies (1 randomized controlled trial and 5 cohort studies) met inclusion criteria, and included 272,545 patients (VKA: 108,666; DOAC: 163,879— dabigatran: 21,954; rivaroxaban: 68,151; apixaban: 62,961; edoxaban: 10,813). The mean patient age was 83.7 years, and 63.9% were female. Apixaban was associated with a significant reduction in stroke/systemic embolism (2.40% vs. 4.32%; OR: 0.56, 95% CI: 0.33–0.95; p=0.03) and major bleeding (4.36% vs. 6.85%; OR: 0.52, 95% CI: 0.29–0.95; p=0.03) compared with VKAs. No significant differences were observed between VKAs and dabigatran, rivaroxaban or edoxaban for either outcome.

Conclusion: Among frail patients with AF, apixaban was associated with lower rates of stroke/systemic embolism and major bleeding compared with VKAs. Other DOACs showed no difference in outcomes compared with VKAs. These findings support preferential consideration of apixaban in this high-risk population.