Efficacy and Safety of Direct Oral Anticoagulants in Stable Coronary Artery Disease and Atrial Fibrillation: A Systematic Review and Network Meta-Analysis

Abstract

Direct Oral Anticoagulants (DOACs) , which partially replace warfarin, have been developed as a safe and effective therapy for patients with stable coronary artery disease (SCAD) and atrial fibrillation (AF). However, the choice of DOACs and warfarin remains controversial. We conducted a network meta-analysis (NMA) using randomized controlled trials (RCTs) through a systematic literature review to evaluate the the efficacy and safety of DOACs in SCAD and AF patients. Five RCTs with 6524 patients were included. The results showed that patients taking DOACs had a lower risk of stroke/systemic embolism (OR, 0.64; 95% CI, 0.54-0.76, P < .00001, I 2 = 89%), intracranial bleeding (OR, 0.41; 95% CI, 0.26-0.64, P = .0001, I 2 = 0%), major bleeding (OR, 0.98; 95% CI, 0.81-1.148, P = .80, I 2 = 88%), and all-cause mortality (OR, 1.04; 95% CI, 0.88-1.22, P = .66, I 2 = 51%) than those taking warfarin. Compared to warfarin, rivaroxaban (20 mg, once/day) was more advantageous in preventing stroke/systemic embolism, as was apixaban (5 mg or 2.5 mg, twice/day) in reducing major bleeding (OR, 0.79; 95% CI, 0.48-1.3) and all-cause mortality (OR, 0.97; 95% CI, 0.69-1.4). Different doses of DOACs showed obvious advantages against intracranial hemorrhage, without significant differences. Thus, DOACs have more effective than warfarin in clinical efficacy and safety.