title: Dabigatran Versus Warfarin for Atrial Fibrillation in Real-World Clinical Practice: A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Trial data for the benefits and risks of dabigatran versus warfarin in the treatment of nonvalvular atrial fibrillation are lacking. We sought to review real-world observational evidence for the comparative effectiveness and safety of these agents.
  
  
  RESULTS
  A systematic search of multiple databases was conducted from first available date to March 10, 2015 for longitudinal, observational studies comparing dabigatran with warfarin. Two reviewers evaluated studies for eligibility and extracted hazard ratios for ischemic stroke and gastrointestinal and intracranial bleeding. hazard ratios were pooled using random-effects meta-analysis. Metaregression was performed to assess treatment-effect heterogeneity. We identified 232 unique citations. Seven retrospective cohort studies met study eligibility criteria, with 348 750 patients and a mean follow-up of 2.2 years. In pooled analyses, dabigatran-150 mg was not superior to warfarin in preventing stroke (hazard ratio, 0.92; 95% confidence interval, 0.84-1.01; P=0.066), but had a significantly lower hazard of intracranial bleeding (0.44; 0.34-0.59; P<0.001). Dabigatran-150 mg had a significantly greater hazard of gastrointestinal bleeding than warfarin (1.23; 1.01-1.50; P=0.041), which was potentiated in studies of older (elderly) versus younger populations (median/mean age, ≥75 versus <75 years; β=1.53; 95% confidence interval, 1.10-2.14; P=0.020).
  
  
  CONCLUSIONS
  In real-world clinical practice, dabigatran is comparable with warfarin in preventing ischemic stroke among patients with nonvalvular atrial fibrillation. However, dabigatran is associated with a lower risk for intracranial bleeding relative to warfarin, but-particularly among the elderly-a greater risk for gastrointestinal bleeding. Bleeding outcomes from observational studies are consistent with those from the pivotal Randomized Evaluation of Long-Term Anticoagulation Therapy trial.
authors.affiliation: From the Palo Alto Medical Foundation Research Institute, Palo Alto, CA (R.J.R., L.N., M.D.); and Department of Clinical Pharmacy, University of California, San Francisco (E.K., K.B.O.). romanellir@pamfri.org.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Romanelli
authors.affiliation: From the Palo Alto Medical Foundation Research Institute, Palo Alto, CA (R.J.R., L.N., M.D.); and Department of Clinical Pharmacy, University of California, San Francisco (E.K., K.B.O.).
authors.forename: Laura
authors.initials: L
authors.lastname: Nolting
authors.affiliation: From the Palo Alto Medical Foundation Research Institute, Palo Alto, CA (R.J.R., L.N., M.D.); and Department of Clinical Pharmacy, University of California, San Francisco (E.K., K.B.O.).
authors.forename: Marina
authors.initials: M
authors.lastname: Dolginsky
authors.affiliation: From the Palo Alto Medical Foundation Research Institute, Palo Alto, CA (R.J.R., L.N., M.D.); and Department of Clinical Pharmacy, University of California, San Francisco (E.K., K.B.O.).
authors.forename: Eunice
authors.initials: E
authors.lastname: Kym
authors.affiliation: From the Palo Alto Medical Foundation Research Institute, Palo Alto, CA (R.J.R., L.N., M.D.); and Department of Clinical Pharmacy, University of California, San Francisco (E.K., K.B.O.).
authors.forename: Kathleen B
authors.initials: KB
authors.lastname: Orrico
mesh_terms: D000367:Age Factors; D000368:Aged; D000925:Anticoagulants / Q000009:adverse effects / Q000627:therapeutic use*; D000991:Antithrombins / Q000009:adverse effects / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D000069604:Dabigatran / Q000009:adverse effects / Q000627:therapeutic use*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000139:chemically induced; D006801:Humans; D020300:Intracranial Hemorrhages / Q000139:chemically induced; D008297:Male; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome; D014859:Warfarin / Q000009:adverse effects / Q000627:therapeutic use*
chemical_list: D000925:Anticoagulants; D000991:Antithrombins; D014859:Warfarin; D000069604:Dabigatran
keywords: atrial fibrillation; dabigatran; evidence-based medicine; meta-analysis; stroke