LAUSR

We read with great interest the meta-analysis by Jin et al. [1] comparing the non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in terms of efficacy and safety outcome in patients with diabetes mellitus (DM) and atrial fibrillation (AF). In this study, primary efficacy outcome was stroke or systemic embolism and primary safety outcome was major bleeding. Patients with DM and AF from the RE-LY, ENGAGE AFTIMI 48, ARISTOTLE and ROCKET-AF trials were included in the present study. The present meta-analysis reported that in patients suffering from AF and DM, dabigatran 110mg (bid) firstly, followed by rivaroxaban 20mg, was more likely to become the choice for its performance in preventing systemic embolism or stroke and major bleeding. Here, we would like to discuss some important points about this study. Firstly, there is no information about duration of diabetes, diabetes type, glycemic control, and Hb A1c levels (except RE-LY trial) in enrolled patients with DM. In the current EHRA position paper chaired by Bulent Gorenek [2], it was stated that longer diabetes duration and worse glycemic control increased the risk of AF and its complications. In addition, up to 30–40% of DM patients also have concomitant chronic kidney disease (CKD). 2020 CCS/ CHRS Guidelines on Management of AF reported that AF patients with CKD represent a particularly high-risk subgroup and emphasised that stroke, mortality, and major bleeding all increase as renal function deteriorates [3]. These trials included a small number of patients with a creatinine clearances <30mL/min. In our opinion, it will be more valuable to consider the duration of diabetes, diabetes type, glycemic control and renal functions in the studies conducted to determine the effectiveness and safety of NOAC treatment in patients with AF and DM.