Comparison of Apixaban, Rivaroxaban, Dabigatran, and Vitamin K Antagonists in Patients With Atrial Fibrillation and Liver Disease: A Network Meta-Analysis

Atrial fibrillation (AF) patients with liver disease present unique challenges in anticoagulation management due to increased risks of both thromboembolism and bleeding. This network meta-analysis aimed to compare the efficacy and safety of direct oral anticoagulants (DOACs), apixaban, rivaroxaban, and dabigatran, with vitamin K antagonists (VKAs) in this specific patient population. We conducted a comprehensive literature search across multiple databases, identifying seven studies (six observational and one randomized controlled trial) that met our inclusion criteria. The primary outcomes were the risk of stroke or systemic embolism (SE) and bleeding events. Our analysis revealed that all three DOACs demonstrated superior efficacy and safety profiles compared to VKAs. Apixaban showed the most favorable outcomes, with the highest probability of being the most effective in preventing both stroke/SE (RR: 0.51, 95% CI: 0.38-0.67) and bleeding events (RR: 0.54, 95% CI: 0.43-0.69). Rivaroxaban and dabigatran also significantly reduced the risk of these outcomes compared to VKAs but to a lesser extent than apixaban. Notably, rivaroxaban was associated with a slightly increased bleeding risk compared to apixaban (RR: 0.76, 95% CI: 0.58-0.99). The consistency of our network model was confirmed through both global and local tests. While these findings provide valuable guidance for clinicians, the study's limitations, including the predominance of observational data, highlight the need for large-scale randomized controlled trials. Future research should focus on clearly defined anticoagulant dosing regimens and comprehensive assessments of cirrhosis status to further optimize anticoagulation strategies in AF patients with liver disease.