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Li R, Yuan M, Cheng J, et al. Risk of post-thrombotic syndrome after deep vein thrombosis treated with rivaroxaban versus vitamin-K antagonists: A systematic review and meta-analysis. Thromb Res. 2020 Sep 17;196:340-348. doi: 10.1016/j.thromres.2020.09.014. (Systematic review)

INTRODUCTION: Post-thrombotic syndrome (PTS) is a burdensome long-term complication of deep vein thrombosis (DVT). Recent studies have suggested that rivaroxaban may reduce PTS events compared to vitamin-K antagonists (VKAs). We, therefore, systematically reviewed available literature that compared rivaroxaban versus VKAs on the risk of PTS.

MATERIALS AND METHODS: We conducted a systematic review and meta-analysis using PubMed, EMBASE and Cochrane Library for all related studies from inception until March 2020. Two reviewers independently screened studies, extracted data, and appraised the quality of included studies. The primary outcome was overall risk of PTS. The secondary outcomes were risks of each PTS category (mild, moderate, severe) and venous ulcer.

RESULTS: Seven comparative studies, comprising 2364 participants, qualified for this meta-analysis. The use of rivaroxaban for DVT treatment was associated with a lower risk of PTS compared with conventional VKAs [pooled unadjusted odds ratio (OR): 0.53, 95%CI: 0.43-0.65, P < 0.00001]. This effect was maintained after adjustment of potential confounders (pooled adjusted OR: 0.44, 95%CI: 0.35-0.56, P < 0.00001). Furthermore, rivaroxaban therapy was found to be associated with reduced risk of mild PTS (OR: 0.64, 95%CI: 0.50-0.82, P = 0.0005), moderate PTS (OR: 0.64, 95%CI: 0.45-0.91, P = 0.01), and severe PTS (OR: 0.52, 95%CI: 0.33-0.82, P = 0.005). There was also a similar trend towards reduced risk for venous ulcer, albeit not statistically significant (OR: 0.41, 95%CI: 0.15-1.08, P = 0.07).

CONCLUSION: In comparison to VKAs, the use of rivaroxaban for DVT treatment has the potential to reduce PTS events. However, well-designed studies with larger sample sizes are needed to corroborate these findings.

Discipline Area Score
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Internal Medicine 6 / 7
Hemostasis and Thrombosis 5 / 7
Comments from MORE raters

Family Medicine (FM)/General Practice (GP) rater

PTS is definitely an important problem in family medicine, where long term observation and care are paramount. However this is supporting evidence at best with its few small and non-randomized studies.

Family Medicine (FM)/General Practice (GP) rater

The results of this metanalysis are very beneficial in the primary care setting where patients may prefer the new anticoagulants over warfarin or coumadin, the vitamin K antagonists. The results are strikingly positive in favor of rivaroxaban to decrease the risk of the post-thrombotic syndrome after DVT. The odds ratio is 0.53 with a narrow CI between 043 and 0.65. However, one should note that the metanalysis included only 7 articles - only one of them was an RCT. The rest were equally divided between cross sectional and prospective cohort studies.

Hemostasis and Thrombosis rater

Only one RCT included here!

Hemostasis and Thrombosis rater

Taking into consideration that rivaroxaban was not better than standard care in acute VTE studies and the nature of the included studies (mostly observational), the conclusion that rivaroxaban will reduce PTS rates still needs to be validated.
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