Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis
Why the study?
Do direct acting oral anticoagulants reduce stroke or systemic embolism and improve safety compared to warfarin in patients with atrial fibrillation?
Population
94,656 patients with atrial fibrillation pooled from 23 randomized trials
Comparison
Direct acting oral anticoagulants including… vs Warfarin dosed to achieve a target INR of 2.0-3.0
Design
Meta-analysis, Included studies were randomised trials
Authors
Discussion
Loading...
Member takes
Implication
Apixaban and dabigatran should be prioritized over warfarin for AF stroke prevention; confirms network meta-analysis ranking of DOAC options.
Key Points
- To evaluate and compare the efficacy, safety, and cost effectiveness of direct-acting oral anticoagulants against warfarin and antiplatelet therapy for stroke prevention in atrial fibrillation.
- Systematic review, network meta-analysis, and cost effectiveness analysis searching Medline, PreMedline, Embase, and The Cochrane Library (PROSPERO CRD 42013005324).
- Analyzed 23 randomized trials involving 94,656 patients with atrial fibrillation comparing direct oral anticoagulants, vitamin K antagonists (target INR 2.0–3.0), or antiplatelet drugs.
- Stroke or systemic embolism risk compared with warfarin was significantly reduced with apixaban 5 mg twice daily (OR 0.79, 95% CI 0.66 to 0.94) and dabigatran 150 mg twice daily (OR 0.65, 95% CI 0.52 to 0.81), and all direct oral anticoagulants reduced all-cause mortality.
- Major bleeding risk was lower versus warfarin with apixaban 5 mg twice daily (OR 0.71, 95% CI 0.61 to 0.81), dabigatran 110 mg twice daily (OR 0.80, 95% CI 0.69 to 0.93), edoxaban 30 mg once daily (OR 0.46, 95% CI 0.40 to 0.54), and edoxaban 60 mg once daily (OR 0.78, 95% CI 0.69 to 0.90).
- Major bleeding risk was higher with dabigatran 150 mg (OR 1.33, 95% CI 1.09 to 1.62) and rivaroxaban 20 mg (OR 1.45, 95% CI 1.19 to 1.78) compared to apixaban 5 mg, with apixaban ranking highest overall and proving cost effective.
Structured PICO
Do direct acting oral anticoagulants reduce stroke or systemic embolism and improve safety compared to warfarin in patients with atrial fibrillation?
P
Population
94,656 patients with atrial fibrillation pooled from 23 randomized trials
I
Intervention
Direct acting oral anticoagulants (DOACs) including apixaban (5 mg twice daily), dabigatran (110 mg or 150 mg twice daily), edoxaban (30 mg or 60 mg once daily), and rivaroxaban (20 mg once daily)
C
Comparator
Warfarin dosed to achieve a target INR of 2.0-3.0 (or other DOACs via indirect network comparison)
O
Outcome
Stroke or systemic embolismhard clinical
Several DOACs provide a net clinical benefit over warfarin for stroke prevention in atrial fibrillation, with apixaban 5 mg twice daily ranking highest for most efficacy and safety outcomes.
Limitations
- Reliance on indirect comparisons through network meta-analysis due to lack of head-to-head DOAC trials
Cite This Study
López-López et al. (2017) studied this question.