SynthesisHeart (British Cardiac Society)2023
Outcomes and drivers of inappropriate dosing of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation: a systematic review and meta-analysis.
Synthesis in Heart (British Cardiac Society), 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 31 papers, 4 of them syntheses that pooled it.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
31 citing papers in PubMed, 4 syntheses or guidelines pooled it, 48 citations in OpenAlex.
- Residual Stroke Risk Among Patients With Atrial Fibrillation Prescribed Oral Anticoagulants: A Patient-Level Meta-Analysis From COMBINE AF.Journal of the American Heart Association · 2024Pooled it
- Potentially inappropriate prescribing in multimorbid and polymedicated older adults with AF: A Systematic Review and Meta-Analysis.Drugs & aging · 2024Pooled it
- Comparisons of effectiveness and safety between on-label dosing, off-label underdosing, and off-label overdosing in Asian and non-Asian atrial fibrillation patients treated with rivaroxaban: a systematic review and meta-analysis of observational studies.Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology · 2023Pooled it
- Pooled it
- Clinical decision support tool evaluation: Correction of direct oral anticoagulant dosing errors by clinical pharmacists and physicians.Research and practice in thrombosis and haemostasis · 2026Trial
- Access to clinical data for direct oral anticoagulant prescriptions in community pharmacy and implications for medication optimisation: a mixed-methods study.International journal of clinical pharmacy · 2026Article
- Oral anticoagulant switching in patients with atrial fibrillation: a long-term cohort study using population-level administrative data.International journal of clinical pharmacy · 2026Article
- Implementing anticoagulation stewardship: the use of a dedicated mobile phone 'app' in the experience of the Italian Federation of Anticoagulation linics (FCSA).Journal of thrombosis and thrombolysis · 2026Article
- Antithrombotic Polymers: A Narrative Review on Current and Future Strategies for Their Design, Synthesis, and Application.International journal of molecular sciences · 2026Review
- Methods Article for a Study Protocol: Refining Stroke Prediction in Atrial Fibrillation Patients in an Ethnically Diverse Population - A Study Protocol.Neuroepidemiology · 2026Article
- Prevalence of Major Bleeding in Elderly Patients on Oral Anticoagulants for Non-Valvular Atrial Fibrillation: A Single-Center 12-Year Retrospective Review.Geriatrics (Basel, Switzerland) · 2025Article
- Impact of Age and Factor Xa Inhibitor Concentrations on Bleeding Risk in Patients with Atrial Fibrillation.Clinical pharmacology and therapeutics · 2025Article
- Reduced dose direct oral anticoagulants and time-in-therapeutic-range defined warfarin in new-onset atrial fibrillation: a report from the nationwide FinACAF study.European heart journal open · 2025Article
- Does hospitalisation improve oral anticoagulant optimisation in patients with atrial fibrillation?European journal of clinical investigation · 2025Observational
- Current Real-World Status of Off-Label Under- and Over-Dose of Direct Oral Anticoagulants After Atrial Fibrillation Ablation.Journal of cardiovascular electrophysiology · 2025Observational
- Direct-Acting Oral Anticoagulants and Potential Inconsistencies with FDA-Approved Dosing for Non-Valvular Atrial Fibrillation: A Retrospective Real-World Analysis Across Nine US Healthcare Systems.Journal of general internal medicine · 2025Article
- 2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.Circulation · 2025Review
- Prevalence, risk characteristics, and prediction of low-dose edoxaban treatment in hospitalized patients: a multicenter, observational cohort study.Frontiers in pharmacology · 2025Article
- Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation at a tertiary care hospital in Thailand.Exploratory research in clinical and social pharmacy · 2024Article
- Predictors and Outcomes of Inappropriate Dosing of Direct Oral Anticoagulants in Patients Receiving Transcatheter Aortic Valve Implantation.Cardiology and therapy · 2024Article
Corrections and comments
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Authors and funding
14 authors at 10 institutions in 8 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveThere has been limited systematic evaluation of outcomes and drivers of inappropriate non-vitamin K antagonist oral anticoagulants (NOACs) dosing among patients with atrial fibrillation (AF). This review identified and systematically evaluated literature on clinical and economic outcomes of inappropriate NOAC dosing and associated patient characteristics.
methodsMEDLINE, Embase, Cochrane Library, International Pharmaceutical Abstracts, Econlit, PubMed and NHS EEDs databases were searched for English language observational studies from all geographies published between 2008 and 2020, examining outcomes of, or factors associated with, inappropriate NOAC dosing in adult patients with AF.
resultsOne hundred and six studies were included in the analysis. Meta-analysis showed that compared with recommended NOAC dosing, off-label underdosing was associated with a null effect on stroke outcomes (ischaemic stroke and stroke/transient ischaemic attack (TIA), stroke/systemic embolism (SE) and stroke/SE/TIA). Meta-analysis of 15 studies examining clinical outcomes of inappropriate NOAC dosing found a null effect of underdosing on bleeding outcomes (major bleeding HR=1.04, 95% CI 0.90 to 1.19; p=0.625) but an increased risk of all-cause mortality (HR=1.28, 95% CI 1.10 to 1.49; p=0.006). Overdosing was associated with an increased risk of major bleeding (HR=1.41, 95% CI 1.07 to 1.85; p=0.013). No studies were found examining economic outcomes of inappropriate NOAC dosing. Narrative synthesis of 12 studies examining drivers of inappropriate NOAC dosing found that increased age, history of minor bleeds, hypertension, congestive heart failure and low creatine clearance (CrCl) were associated with an increased risk of underdosing. There was insufficient evidence to assess drivers of overdosing.
conclusionsOur analysis suggests that off-label underdosing of NOACs does not reduce bleeding outcomes. Patients prescribed off-label NOAC doses are at an increased risk of all-cause mortality. These data underscore the importance of prescriber adherence to NOAC dosing guidelines to achieve optimal clinical outcomes for patients with AF. PROSPERO REGISTRATION NUMBER: CRD42020219844.
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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.