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Anticoagulation regimens during pregnancy in patients with mechanical heart valves: a protocol for a systematic review and network meta-analysis
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  • Published on:
    Why network meta-analysis cannot be used to determine the optimal method of anticoagulation in pregnant women with mechanical heart valves
    • Rohan D'Souza, Maternal-Fetal Medicine Physician Mount Sinai Hospital, University of Toronto, Canada
    • Other Contributors:
      • Prakesh S Shah, Neonatologist
      • Claire McLintock, Haematologist

    Dear editor,

    We read with interest, the study protocol by He. et al, comparing anticoagulation strategies in pregnant women with mechanical heart valves (MHVs)[1]. In their protocol, the authors propose the conduct of a network meta-analysis (NMA) to compare various strategies for anticoagulation in this population. The proposed protocol adds to a long list of recently-published systematic reviews on the topic, each of which adopted slightly different methodological approaches, resulting in the drawing of disparate clinical conclusions. The reason for this is the considerable clinical, methodological and statistical heterogeneity within published studies, most of which case series and small cohort studies[2]. Although this protocol has a number of strengths, which includes an exhaustive list of databases, clear definitions of outcomes and the use of GRADE methodology to assess the certainty in evidence and the strength of recommendations, there are a few concerns that must be addressed.

    The choice of anticoagulant in pregnant women with MHVs is often based on resource availability and clinical factors. For example, the use of low molecular weight heparin is cost-prohibitive in low-resource settings and where serial anti-Xa levels cannot be monitored. In settings where a choice of all methods is available, those at highest risk, still receive a vitamin-K-antagonist-based regimen. Further, clinical outcomes are considerably different in lower resource setting...

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    Conflict of Interest:
    None declared.