{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T20:39:05Z","timestamp":1770669545706,"version":"3.49.0"},"reference-count":54,"publisher":"Oxford University Press (OUP)","issue":"10","license":[{"start":{"date-parts":[[2023,9,20]],"date-time":"2023-09-20T00:00:00Z","timestamp":1695168000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,10,5]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Aims<\/jats:title>\n                  <jats:p>Limited real-world data show that rivaroxaban following dosage criteria from either ROCKET AF [20\u2005mg\/day or 15\u2005mg\/day if creatinine clearance (CrCl) &amp;lt; 50\u2005mL\/min] or J-ROCKET AF (15\u2005mg\/day or 10\u2005mg\/day if CrCl &amp;lt; 50\u2005mL\/min) is associated with comparable risks of thromboembolism and bleeding with each other in patients with non-valvular atrial fibrillation (NVAF). We are aimed to study whether these observations differ between Asian and non-Asian subjects.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods and results<\/jats:title>\n                  <jats:p>A systematic review and meta-analysis with random effects was conducted to estimate the aggregate hazard ratio (HR) and 95% confidence interval (CI) using PubMed and MEDLINE databases from 8 September 2011 to 31 December 2022 searched for adjusted observational studies that reported relevant clinical outcomes of NVAF patients receiving rivaroxaban 10\u2005mg\/day if CrCl &amp;gt; 50\u2005mL\/min, on-label dose rivaroxaban eligible for ROCKET AF or J-ROCKET AF, and rivaroxaban 20\u2005mg\/day if CrCl &amp;lt; 50\u2005mL\/min. Effectiveness and safety endpoints were compared between ROCKET AF and J-ROCKET AF dosing regimen in Asian and non-Asian subjects, separately. Also, risks of events of rivaroxaban 10\u2005mg\/day despite of CrCl &amp;gt; 50\u2005mL\/min and rivaroxaban 20\u2005mg\/day despite of CrCl &amp;lt; 50\u2005mL\/min were compared to that of \u2018ROCKET AF\/J-ROCKET AF dosing\u2019. Sensitivity analyses were performed by sequential elimination of each study from the pool. The meta-regression analysis was performed to explore the influence of potential factors on the effectiveness and safety outcomes. Eighteen studies involving 67 571 Asian and 54 882 non-Asian patients were included. Rivaroxaban following J-ROCKET AF criteria was associated with comparable risks of thromboembolism in the Asian subgroup, whereas rivaroxaban following J-ROCKET AF criteria was associated with higher risks of all-cause mortality (HR:1.30; 95% CI:1.05\u20131.60) compared with that of ROCKET AF criteria in the non-Asian population. There were no differences in risks of major bleeding between rivaroxaban following J-ROCKET AF vs. ROCKET AF criteria either in the Asian or non-Asian population. The use of rivaroxaban 10\u2005mg despite of CrCl &amp;gt; 50\u2005mL\/min was associated with a higher risk of thromboembolism (HR:1.64; 95% CI:1.28\u20132.11) but lower risk of major bleeding (HR:0.72; 95% CI:0.57\u20130.90) compared with eligible dosage criteria. The use of rivaroxaban 20\u2005mg despite of CrCl &amp;lt; 50\u2005mL\/min was associated with worse clinical outcomes in the risks of thromboembolism (HR:1.32; 95% CI:1.09\u20131.59), mortality (HR:1.33; 95% CI:1.10\u20131.59), and major bleeding (HR:1.26; 95% CI:1.03\u20131.53) compared with eligible dosage criteria. The pooled results were generally in line with the primary effectiveness and safety outcomes by removing a single study at one time. Meta-regression analyses failed to detect the bias in most potential patient characteristics associated with the clinical outcomes.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>Rivaroxaban dosing regimen following J-ROCKET criteria may serve as an alternative to ROCKET AF criteria for the Asian population with NVAF, whereas the dosing regimen following ROCKET AF criteria was more favourable for the non-Asian population. The use of rivaroxaban 10\u2005mg despite of CrCl &amp;gt; 50\u2005mL\/min was associated with a higher risk of thromboembolism but a lower risk of major bleeding, while use of rivaroxaban 20\u2005mg despite of CrCl &amp;lt; 50\u2005mL\/min was associated with worse outcome in most clinical events.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/europace\/euad288","type":"journal-article","created":{"date-parts":[[2023,9,22]],"date-time":"2023-09-22T18:51:53Z","timestamp":1695408713000},"source":"Crossref","is-referenced-by-count":16,"title":["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"],"prefix":"10.1093","volume":"25","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1406-8503","authenticated-orcid":false,"given":"Yi-Hsin","family":"Chan","sequence":"first","affiliation":[{"name":"Cardiovascular Department, Chang Gung Memorial Hospital , Linkou , Taoyuan 33305, Taiwan"},{"name":"College of Medicine, Chang Gung University , Taoyuan 33302 , Taiwan"},{"name":"Microscopy Core Laboratory, Chang Gung Memorial Hospital , Linkou , Taoyuan 33305, Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-4267-3771","authenticated-orcid":false,"given":"Chih-Yu","family":"Chan","sequence":"additional","affiliation":[{"name":"College of Medicine, Chang Gung University , Taoyuan 33302 , Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1674-1295","authenticated-orcid":false,"given":"Shao-Wei","family":"Chen","sequence":"additional","affiliation":[{"name":"Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University , Taoyuan , Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6587-3094","authenticated-orcid":false,"given":"Tze-Fan","family":"Chao","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital , Taipei 11217 , Taiwan"},{"name":"Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University , Taipei 112304 , Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7566-1626","authenticated-orcid":false,"given":"Gregory Y H","family":"Lip","sequence":"additional","affiliation":[{"name":"Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital , Liverpool , UK"},{"name":"Department of Clinical Medicine, Aalborg University , Aalborg , Denmark"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2023,9,20]]},"reference":[{"key":"2023101711254271700_euad288-B1","doi-asserted-by":"crossref","first-page":"883","DOI":"10.1056\/NEJMoa1009638","article-title":"Rivaroxaban versus warfarin in nonvalvular atrial fibrillation","volume":"365","author":"Patel","year":"2011","journal-title":"N Engl J Med"},{"key":"2023101711254271700_euad288-B2","doi-asserted-by":"crossref","first-page":"2104","DOI":"10.1253\/circj.CJ-12-0454","article-title":"Rivaroxaban vs. warfarin in Japanese patients with atrial fibrillation\u2014the J-ROCKET AF study","volume":"76","author":"Hori","year":"2012","journal-title":"Circ J"},{"key":"2023101711254271700_euad288-B3","doi-asserted-by":"crossref","first-page":"581293","DOI":"10.3389\/fphar.2021.581293","article-title":"Real-world prevalence of direct oral anticoagulant off-label doses in atrial fibrillation: an epidemiological meta-analysis","volume":"12","author":"Shen","year":"2021","journal-title":"Front Pharmacol"},{"key":"2023101711254271700_euad288-B4","doi-asserted-by":"crossref","first-page":"2008","DOI":"10.1001\/jama.283.15.2008","article-title":"Meta-analysis of observational studies in epidemiology: a proposal for reporting. 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