title: Efficacy and safety of direct oral anticoagulants in patients undergoing cardioversion for atrial fibrillation: A systematic review and meta-analysis of the literature.
abstract: BACKGROUND
  DOACs are increasingly used in patients with NVAF. Information on efficacy and safety of these compounds in patients undergoing electrical or pharmacological cardioversion is limited. Thus, we performed a systematic review and a meta-analysis of the literature to address this issue.
  
  
  METHODS
  Randomized controlled trials comparing the efficacy and safety of DOACs and VKAs in patients with NVAF were systematically searched in Medline, Web of Science, Scopus, Cochrane, and EMBASE databases (up to September 2014). Pooled relative risk (RR) and the corresponding 95% confidence interval (CI) were calculated for each outcome.
  
  
  RESULTS
  Four randomized controlled trials (3635 patients), for a total of 4517 cardioversions (2869 with DOACs and 1648 with VKAs), were included in the analysis. DOACs and VKAs appeared equally effective in the prevention of stroke/systemic embolism (0.41% vs 0.61%; RR: 0.73, 95% CI: 0.31, 1.72; P=0.48) and of post-cardiovascular death (0.52% vs 0.81%; RR: 0.73, 95% CI: 0.27, 2.03; P=0.55), with a similar risk of major bleeding complications (0.81% vs 0.60%; RR: 1.23, 95% CI: 0.55, 2.71). Heterogeneity among studies was generally absent. Furthermore, the Weighted Mean Incidence (WMI) of complications appeared very low in patients randomized to DOACs (WMI: 0.6% and 0.9% for stroke/systemic embolism and major bleeding, respectively).
  
  
  CONCLUSIONS
  Our results suggest that DOACs are at least as effective and safe as VKAs in patients with NVAF undergoing to an electrical or pharmacological cardioversion. Thus, DOACs may be considered a valid and practical alternative to VKAs.
authors: Department of Clinical Medicine, Insubria University, Varese, Italy. Electronic address: fdentali@libero.it.
authors: Francesco
authors: F
authors: Dentali
authors: EP Unit, Department of Medicine, Sant'Anna Hospital, Como, Italy.
authors: Giovanni Luca
authors: GL
authors: Botto
authors: Department of Cardiology, Hospital of Tradate, Tradate, Italy.
authors: Monica
authors: M
authors: Gianni
authors: Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy.
authors: Pasquale
authors: P
authors: Ambrosino
authors: Unit of cell and molecular biology in cardiovascular diseases, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
authors: Matteo Nicola Dario
authors: MN
authors: Di Minno
mesh_terms: D000284:Administration, Oral; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000628:therapy*; D004554:Electric Countershock; D004617:Embolism / Q000517:prevention & control*; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000517:prevention & control*; D014812:Vitamin K / Q000037:antagonists & inhibitors
chemical_list: D000925:Anticoagulants; D014812:Vitamin K
keywords: Atrial fibrillation; Cardioversion; Direct oral anticoagulants