Direct oral anticoagulants versus vitamin K antagonists in concurrent hypertrophic cardiomyopathy and atrial fibrillation: a meta-analysis

Twenty to twenty-five percent of patients with hypertrophic cardiomyopathy (HCM) have concurrent atrial fibrillation (AF). It is unclear whether direct oral anticoagulants (DOAC) are a safe and effective alternative to vitamin K antagonists (VKA) in concurrent HCM and AF. We performed a systematic review and meta-analysis of original reports comparing DOACs versus VKAs in concurrent HCM and AF. The protocol was published in PROSPERO -CRD42024575553. MEDLINE, Embase, and Cochrane Central were searched from inception to October 2024. From 1119 records retrieved by the search, we identified 8 different observational studies (<i>n</i> = 14,243). Compared to VKAs, DOACs were associated with a lower rate of thromboembolic events 318/8322 vs. 559/5921 (OR 0.44, 95% CI 0.23-0.83; <i>p</i> = 0.0118; I² = 84%; NNT = 18), and less major bleeds 289/8322 vs. 327/5921 (OR 0.54, 95% CI 0.36-0.80; <i>p</i> = 0.0021; I²  = 76%; NNT = 49). Apixaban and dabigatran were associated with lower rate of thromboembolic events, major bleeding, all-cause death, and intracranial hemorrhage, and Rivaroxaban associated with less all-cause deaths and intracranial hemorrhages, compared to VKAs (all <i>p</i> &lt; 0.05). DOACs demonstrated good efficacy and a favorable safety profile in patients with HCM and AF compared to VKAs. Registration: The protocol for this meta-analysis was published in PROSPERO (CRD420245755530).