Title

Anticoagulant use in patients with atrial fibrillation and thrombocytopenia: a systematic review and meta-analysis


Authors

Diego Napoleon Medina1, Karen Quintanilla-Apaza1, Daniel Medina-Neira1, Adriana Romero-Rodríguez1, Danfranco Samuel Vega1, Grace Garcia-Huaman1, Camila Bedregal-Zuñiga1, Fernanda Lopez-Zegarra1, Omar Bellota-Segovia1, Albert Gabriel Turpo-Peqqueña1, Luis Alvarez-Ankass1

1Catholic University of Santa María


Introduction

Anticoagulation is the standard therapy to prevent stroke and systemic embolism in patients with atrial fibrillation1,2. However, severe thrombocytopenia is often viewed as a relative contraindication despite limited evidence from case reports and low-quality observational studies3. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of anticoagulants compared with no anticoagulation in patients with atrial fibrillation and thrombocytopenia.


Methods

All clinical trials and observational studies with a control group were eligible for inclusion. Eligible studies involved patients with nonvalvular AF and thrombocytopenia, comparing any anticoagulation (warfarin, direct oral anticoagulants, or heparin) to a control group without anticoagulation. Primary outcomes of interest were stroke or systemic embolism, major bleeding, and all-cause mortality. On October 9, 2025, we searched CENTRAL, MEDLINE, Embase, Scopus, Web of Science Core Collection (SCI-EXPANDED, ESCI, CPCI-S), ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. After duplicate removal, two reviewers independently used ASReview for screening, followed by a full-text review of potentially relevant studies. Two reviewers collected information using a standardized extraction form. Risk of bias and certainty of evidence were assessed independently by two reviewers. A third reviewer resolved discrepancies in any part of the process. We included articles, conference abstracts, and reports regardless of publication status. Data were pooled using a random-effect model or a fixed-effect model if fewer than 2 effect measures were available. We also conducted subgroup analyses and sensitivity analyses.


Results

From 3647 screened records, this review included 4 observational studies4–7 with 2484 patients. Three studies were done in patients with malignancies. Most studies followed patients for 30 days, except one study, where participants were followed until the occurrence of study outcomes (1 to 3 years). The mean platelet count in studies of patients with concurrent malignancies was 36.76 × 109/L, and 66.96 × 109/L without cancer. There were no statistically significant differences between the anticoagulation and no anticoagulation groups for stroke or systemic embolism (aHR = 0.46 [95% CI: 0.14, 1.49], RR = 1.30 [95% CI: 0.63, 2.68]), major bleeding (aHR = 0.56 [95% CI: 0.24, 1.28], RR = 0.36 [95% CI: 0.25, 0.53]), and all-cause mortality (RR = 0.81 [95% CI: 0.30, 2.22]).

Table. Summary of findings


Conclusion

In patients with atrial fibrillation and thrombocytopenia, current evidence from observational controlled studies suggests that there are no significant differences in efficacy and safety between patients receiving anticoagulation and those without it.


References

  1. Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024;149(1):e1–156.
  2. Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): Developed by the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC), with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Endorsed by the European Stroke Organisation (ESO). Eur Heart J 2024;45(36):3314–414.
  3. Iijima RT Masahide; Nakamura, Masato; Yasuda, Satoshi; Kaikita, Koichi; Akao, Masaharu; Ako, Junya; Matoba, Tetsuya; Miyauchi, Katsumi; Hagiwara, Nobuhisa; Kimura, Kazuo; Hirayama, Atsushi; Matsui, Kunihiko; Ogawa, Hisao. Thrombocytopenia as a Bleeding Risk Factor in Atrial Fibrillation and Coronary Artery Disease: Insights From the AFIRE Study. J Am Heart Assoc 2023;12(20):e031096.
  4. Drozdinsky GA Noam; Spectre, Galia; Livneh, Nir; Poran, Itamar; Raanani, Pia; Falanga, Anna; Ten Cate, Hugo; Gafter Gvili, Anat; Leader, Avi. Anticoagulation in cancer patients with atrial fibrillation and grade 3-4 thrombocytopenia. Thromb Res 2024;235((Drozdinsky G.; Poran I.) Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel):92.
  5. Livneh NB Dionne; Drozdinsky, Genady; Gafter Gvili, Anat; Seelig, Jaap; Rozovski, Uri; Berger, Tamar; Raanani, Pia; Falanga, Anna; Ten Cate, Hugo; Spectre, Galia; Leader, Avi. Anticoagulation in patients with atrial fibrillation, thrombocytopenia and hematological malignancy. J Thromb Thrombolysis 2021;52(2):590.
  6. Yeh YHC Yi Hsin; Chen, Shao Wei; Chang, Shang Hung; Wang, Chun Li; Kuo, Chi Tai; Lip, Gregory YH; Chen, Shih Ann; Chao, Tze Fan. Oral Anticoagulant Use for Patients with Atrial Fibrillation with Concomitant Anemia and/or Thrombocytopenia. Am J Med 2022;135(8):e248.
  7. Leader A; S G; Chistolini, A; Beckers, E; Elling, T; Beggiato, E; Hamulyák, E; Ram, R; Cerqui, E; Samuelson Bannow, B; Siragusa, S; Carrer, A; Avnery, O; Del Principe, M; Giaccherini, C; Russo, L; Schieppati, F; ten Cate Hoek, A; ten Cate, H; Falanga, A. Management Patterns of Antithrombotics and Outcomes in Patients with Hematological Malignancy and Thrombocytopenia: A Prospective Registry (Matter Study). Res Pract Thromb Haemost [Internet] 2023;7((Leader A.; Spectre G.) Institute of Hematology, Rabin Medical Center, Petah Tikva, Petah Tikva, HaMerkaz, Israel). Available from: https://www.embase.com/search/results?subaction=viewrecord&id=L2028295051&from=export