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Background: AF is a global health concern, with systemic complications including renal dysfunction. This systematic review and meta-analysis compares the effects of rivaroxaban, a Factor Xa inhibitor, and vitamin K antagonists (VKAs) on renal outcomes in AF patients., Methods: The study protocol is registered in PROSPERO (ID: CRD42023462756). We systematically searched the PubMed, Embase and Cochrane Library databases from 1 January 2017 to 30 June 2023 for real-world studies comparing the effects of rivaroxaban and VKAs on renal outcomes in AF patients, including acute kidney injury, a .30% decrease in estimated glomerular filtration rate, doubling of serum creatinine and worsening renal function. Subgroup analyses targeted diabetes, pre-existing kidney disease, the elderly (age .65 years) and Asian populations. The risk of bias was assessed used the Robins-I tool. HRs and 95% CIs were synthesised through a random-effects model. Two sensitivity analyses were performed, using a fixed-effects model and excluding conference abstracts., Results: We identified 1,666 records. After screening, 14 studies comparing rivaroxaban and VKAs were included. Rivaroxaban exhibited superiority over VKAs in preventing: acute kidney injury (HR 0.68; 95% CI [0.61.0.77]; p<0.00001); a .30% decrease in estimated glomerular filtration rate (HR 0.71; 95% CI [0.60.0.84]; p<0.0001); doubling of serum creatinine (HR 0.50; 95% CI [0.36.0.70]; p<0.0001); and worsening renal function (HR 0.56; 95% CI [0.45.0.69]; p<0.00001). Subgroup and sensitivity analyses consistently confirmed rivaroxaban's favourable effects on renal outcomes in diabetes, pre-existing kidney disease, the elderly and Asian populations., Conclusion: Our findings support the preference of rivaroxaban over VKAs for renal outcomes in AF. The findings endorse rivaroxaban as the preferred anticoagulant to mitigate renal complications, offering clinicians valuable insights for tailored strategies., Competing Interests: Disclosure: PPD has received honoraria for scientific presentations from Bayer, Boehringer Ingelheim, Astra Zeneca, Novartis, Medtronic, Abbott, Daiichi Sankyo, Pfizer, Sanofi and Merck Serono. THHQ has received honoraria for scientific presentations from Bayer, Boehringer Ingelheim, Astra Zeneca and Menarini. HPM has received honoraria for scientific presentations from Bayer, Servier, Boehringer Ingelheim, Astra Zeneca, Boston Scientific, Medtronic, Abbott, Elixir, Biotronic and Merck Serono. SHV has received honoraria for scientific presentations from Bayer, Boehringer Ingelheim, Astra Zeneca, Menarini, Servier, Merck Serono, Dr. Reddy’s Laboratories and Gedeon Richter. HNH has received honoraria for scientific presentations from Bayer, Boehringer Ingelheim, Pfizer, Merck Serono, Novartis, Sanofi an Roche. NVQ has received honoraria for scientific presentations from Bayer, Boehringer Ingelheim and Pfizer. MTT has received honoraria for scientific presentations from Bayer, Boehringer Ingelheim, Pfizer, Merck Serono and Medtronic. SLC has received honoraria for scientific presentations from Bayer, Boehringer Ingelheim, Astra Zeneca, Novartis, Medtronic, Viatris, Daiichi Sankyo, Pfizer, Otsuka and Merck Serono. All other authors have no conflicts of interest to declare. Funding: The article processing fee was funded by Bayer Vietnam. The funder had no role in the design, execution, interpretation or writing of the study. Data availability: The data are available from the corresponding author upon reasonable request. Trial registration number: CRD42023462756, (Copyright © The Author(s), 2024. Published by Radcliffe Group Ltd.)

In Asia, especially Vietnam, AF is a common arrhythmia and is linked to a higher risk of stroke and systemic embolism. Anticoagulation therapy for stroke prevention in AF patients can result in bleeding complications. To effectively manage AF, adopting appropriate anticoagulation and addressing modifiable risk factors are crucial. Vietnamese clinicians are particularly interested in non-vitamin K antagonist oral anticoagulants (NOACs), a recent development in AF treatment. However, the lack of head-to-head trials comparing NOACs makes selecting a specific NOAC challenging. This review aims to provide a comprehensive overview of the available clinical evidence on NOACs for stroke prevention in AF to assist clinicians in making informed decisions and improving treatment outcomes in patients with AF. The first part of this review will present the current landscape of AF in Vietnam, focusing on AF prevalence and highlighting gaps in clinical practice. Furthermore, this part extensively discusses the anticoagulation strategy for both primary and secondary stroke prevention in AF., Competing Interests: Disclosure: THQH has received honoraria for scientific presentations from Bayer, Pfizer. MTT, VLN and HMP have received honoraria for scientific presentations from Bayer, Pfizer, Boehringer Ingelheim and Daiichi Sankyo. SVH, NTV and TNH have received honoraria for scientific presentations from Bayer, Pfizer and Boehringer Ingelheim. TQN and LTP have received honoraria for scientific presentations from Bayer and Boehringer Ingelheim. TDM has received grants from Bayer for research and honoraria for scientific presentations from Bayer, Pfizer and Boehringer Ingelheim. Funding: The medical writing fee and article processing charge were funded by Bayer Vietnam. The funder had no role in the design, execution, interpretation or writing of the study., (Copyright © The Author(s), 2023. Published by Radcliffe Group Ltd.)

Part 1 of this review provided an overview of AF in Vietnam, with a particular focus on primary and secondary stroke prevention. Part 2 explores the management of AF in special, high-risk and clinically common patient populations, including those with renal impairment, diabetes, the elderly, and those with coronary artery disease. Furthermore, Part 2 addresses the challenges posed by patients with AF who have a bioprosthetic valve, a group situated in a grey area of consideration. Managing AF in these patient groups presents unique clinical challenges that require careful consideration. Physicians are tasked with addressing specific clinical questions to identify the optimal anticoagulation strategy for each individual. To inform these decisions, subgroup analyses from pivotal studies are presented alongside real-world data derived from clinical practice. By synthesising available information and considering the nuanced clinical context, the aim is to provide informed perspectives that align with current medical knowledge and contribute to the enhancement of patient care in these challenging scenarios., Competing Interests: Disclosure: THQH has received honoraria for scientific presentations from Bayer and Pfizer. MTT, VLN and HMP have received honoraria for scientific presentations from Bayer, Pfizer, Boehringer Ingelheim and Daiichi Sankyo. SVH, NTV and TNH have received honoraria for scientific presentations from Bayer, Pfizer and Boehringer Ingelheim. TQN and LTP have received honoraria for scientific presentations from Bayer and Boehringer Ingelheim. TDM has received grants from Bayer for research and honoraria for scientific presentations from Bayer, Pfizer and Boehringer Ingelheim. Funding: The medical writing fee and the article processing charge were funded by Bayer Vietnam. The funder had no role in the design, execution, interpretation or writing of the study., (Copyright © The Author(s), 2023. Published by Radcliffe Group Ltd.)