Direct Oral Anticoagulants Versus Vitamin K Antagonists for Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Abdallah Al-Harrasi, Aaeshah Almutairi, Ruqaiya Ahmed Alghazali, Noor Alrefaei, Reem Said Al Rusheidi, Sarah Al Zuhair, Afnan Kh. E. A. E. A. Alfailakawi, Doaa A. Zamzamy, Hussam Abu Mousa, Mohamed Hamouda Elkasaby, William H. Frishman, Wilbert S. AronowAtrial fibrillation after cardiac surgery is common and is associated with stroke, prolonged hospitalization, and mortality; yet, the optimal oral anticoagulant in this setting remains uncertain. We performed a systematic review and meta-analysis comparing direct oral anticoagulants (DOACs) with vitamin K antagonists (VKAs) in adults requiring oral anticoagulation for atrial fibrillation after cardiac surgery. PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception through August 2026 for randomized controlled trials. The primary outcome was any bleeding; secondary outcomes were stroke or transient ischemic attack, systemic embolism, major bleeding, intracranial hemorrhage, reoperation, and length of hospital stay. Odds ratios (ORs) and mean differences (MDs) were pooled with random-effects models, risk of bias was assessed with the Cochrane Risk of Bias 2 tool, and certainty of evidence was rated with GRADE. Five randomized trials including 302 patients (153 DOACs and 149 warfarin) were included; rivaroxaban was tested in 3 trials, and apixaban and dabigatran in 1 trial each. Any bleeding did not differ significantly between DOACs and VKAs (9.2% vs 8.1%; OR, 1.24; 95% confidence interval [CI], 0.39–3.99).