Relative efficacy and safety of direct oral anticoagulants in patients with atrial fibrillation by network meta-analysis

BackgroundMuch direct evidence has proved that the novel oral anticoagulants (NOACs) are noninferior or superior to warfarin for stroke prevention in patients with nonvalvular atrial fibrillation, and lead to a relevant decrease in bleeding profiles. However, no study has compared NOACs with each other head-to-head. The current study is a network meta-analysis aiming to assess the efficacy and safety of NOACs.MethodsCochrane library, Pubmed NCBI, EMBASE and MEDLINE were systematically searched for randomized controlled trials that assessed the efficacy and safety profiles of NOACs compared with warfarin. The primary outcome was the rate of stroke or systemic embolism, and the secondary outcome was the rate of bleeding events. Network meta-analysis was performed using Markov chain Monte Carlo methods.ResultsA total of four phase III randomized controlled trials (n=71683) met the inclusion criteria. All NOACs except low dose of edoxaban showed noninferior efficacies to warfarin in stroke prevention. In the field of hemorrhage, apixaban was safer than edoxaban 60mg in any bleeding events and had fewer major bleeding events compared with dabigatran 150mg and rivaroxaban.ConclusionNOACs are promising candidates for stroke prevention in patients with nonvalvular atrial fibrillation due to a favorable risk-benefit profile. All NOACs other than edoxaban 30mg had parallel efficacies with respect to stroke prevention. Apixaban had an advantage over the other NOACs in safety.