# Direct Oral Anticoagulants Versus Vitamin K Antagonists in Chronic Kidney Disease Patients Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

## TL;DR

This study compares the effectiveness and safety of direct oral anticoagulants versus vitamin K antagonists in patients with chronic kidney disease undergoing heart valve replacement.

## Contribution

The study provides new evidence that direct oral anticoagulants may be safer and more effective for moderate kidney disease patients after heart valve replacement.

## Key findings

- Direct oral anticoagulants were linked to lower mortality in moderate chronic kidney disease patients.
- Major bleeding and stroke risks were reduced with direct oral anticoagulants in moderate kidney disease patients.
- Direct oral anticoagulants showed comparable safety and better outcomes than vitamin K antagonists in this group.

## Abstract

Chronic kidney disease (CKD) complicates anticoagulation in transcatheter aortic valve replacement (TAVR) patients in some cases. The aim of this review was to compare the efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in this group. We conducted a meta-analysis of 13 studies (32,508 patients) from databases like PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, and Cochrane Library up to September 2024, focusing on all-cause mortality and major bleeding as primary outcomes, with stroke and intracranial hemorrhage as secondary outcomes. DOACs were found associated with reduced mortality (risk ratio (RR): 0.90, 95%CI: 0.81-0.99, p=0.04), particularly in moderate CKD (RR: 0.94, 95%CI: 0.90-0.98, p=0.01). Major bleeding was significantly lower with DOACs in moderate CKD (RR: 0.70, 95%CI: 0.50-0.98, p=0.03), alongside decreased stroke (RR: 0.42, 95%CI: 0.18-0.97) and intracranial hemorrhage (RR: 0.58, 95%CI: 0.36-0.94). DOACs demonstrate superior efficacy in reducing mortality and comparable safety to VKAs in CKD patients post TAVR, especially in moderate CKD. These findings advocate for DOACs as a preferable anticoagulation strategy, with cautious application in severe CKD pending further research.