Comparative Analysis of the Net Clinical Benefit of Direct Oral Anticoagulants in Atrial Fibrillation: Systematic Review and Network Meta-analysis of Randomised Controlled Trials.

European cardiology Pub Date : 2025-05-09 eCollection Date: 2025-01-01 DOI:10.15420/ecr.2025.07
Ton Duy Mai, Tri Huynh Quang Ho, Sy Van Hoang, Hoai Thi Thu Nguyen, Jeyaraj Pandian, Tan Van Nguyen, Khoa Tien Vu, Giang Song Tran, Viet Phuong Dao, Minh Cong Tran, Hung Manh Pham
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Abstract

Background: Direct oral anticoagulants (DOACs) are the standard treatment for stroke prevention in AF. However, high-quality head-to-head comparisons of DOACs are lacking. This study compared oral anticoagulants in patients with AF.

Methods: Data were retrieved from eligible randomised controlled trials (RCTs). Interventions were ranked using the surface under the cumulative ranking curve (SUCRA) and the frequentist random effects model was applied. Efficacy outcomes included stroke, systemic embolism, MI, and all-cause mortality; the safety outcome was major bleeding. A composite outcome of efficacy and net clinical benefit was also evaluated.

Results: From 23,152 records, 11 eligible RCTs were identified and included in the study. Rivaroxaban was superior to vitamin K antagonists (VKA) in net clinical benefit (RR 0.75; 95% CI [0.59-0.94]; p=0.0133), but there were no significant differences between other DOACs and VKA or among the DOACs themselves. Rivaroxaban reduced the risk of the composite outcome of efficacy compared with dabigatran (RR 0.85; 95% CI [0.75-0.98]; p=0.02) and edoxaban (RR 0.84; 95% CI [0.75-0.95]; p=0.0051), but not apixaban (RR 0.89; 95% CI [0.89-1.02]; p=0.087). All DOACs showed superiority over VKA in efficacy, without an increased risk of major bleeding. Based on the SUCRA, rivaroxaban showed a favourable risk-benefit profile compared with the other anticoagulants.

Conclusion: This study showed that DOACs are superior to VKA in efficacy without increasing major bleeding risk, with rivaroxaban demonstrating the most balanced risk-benefit profile. Well-designed RCTs are needed to validate these findings.

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直接口服抗凝剂治疗房颤净临床获益的比较分析:随机对照试验的系统评价和网络荟萃分析。
背景:直接口服抗凝剂(DOACs)是房颤预防卒中的标准治疗方法。然而,缺乏高质量的DOACs的头对头比较。本研究比较了房颤患者口服抗凝剂的疗效。方法:数据来自符合条件的随机对照试验(RCTs)。采用累积排序曲线(SUCRA)下的曲面对干预措施进行排序,采用频率随机效应模型。疗效结局包括中风、全身性栓塞、心肌梗死和全因死亡率;安全性结果为大出血。对疗效和净临床获益的综合结果也进行了评估。结果:从23,152份记录中,确定了11项符合条件的随机对照试验,并将其纳入研究。利伐沙班在净临床获益方面优于维生素K拮抗剂(VKA) (RR 0.75;95% ci [0.59-0.94];p=0.0133),但其他DOACs与VKA之间以及DOACs本身之间无显著差异。与达比加群相比,利伐沙班降低了疗效综合结局的风险(RR 0.85;95% ci [0.75-0.98];p=0.02)和依多沙班(RR 0.84;95% ci [0.75-0.95];p=0.0051),但阿哌沙班没有(RR 0.89;95% ci [0.89-1.02];p = 0.087)。所有DOACs的疗效均优于VKA,且未增加大出血的风险。基于SUCRA,与其他抗凝剂相比,利伐沙班显示出有利的风险-收益特征。结论:本研究显示DOACs在疗效上优于VKA,且未增加大出血风险,其中利伐沙班表现出最平衡的风险-收益特征。需要设计良好的随机对照试验来验证这些发现。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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