Comparative effectiveness and safety of direct acting oral anticoagulants in nonvalvular atrial fibrillation for stroke prevention: a systematic review and meta-analysis

European Journal of Epidemiology - Tập 36 - Trang 793-812 - 2021
Junguo Zhang1, Xiaojie Wang2, Xintong Liu3, Torben B. Larsen4, Daniel M. Witt5, Zebing Ye6, Lehana Thabane7, Guowei Li1,7, Gregory Y. H. Lip8
1Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China
2Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
3Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, China
4Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
5Department of Pharmacotherapy, University of Utah, Salt Lake City, USA
6Department of Cardiology, Guangdong Second Provincial General Hospital, Guangzhou, China
7Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Canada
8Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK

Tóm tắt

Purpose:To systematically review available evidence of indirect comparisons from RCTs and direct comparisons from observational studies regarding the comparative effectiveness and safety of DOACs in patients with AF. Methods: Electronic databases including EMBASE, MEDLINE, and PUBMED were searched up to June 5th, 2020. Primary endpoints included effectiveness (stroke or systemic embolism [SE]) and safety (major bleeding) outcomes. Bucher methods and random-effects models were conducted for indirect and direct comparisons among DOACs, respectively. Ranking probability analyses and the number needed to treat for net effect (NNTnet) were applied. Results: A total of 36 studies, involving 7 RCTs (n = 60,292 patients) and 29 observational studies (n = 1,164,821 patients), were included for analyses. Regarding the risk of stroke/SE, no significant differences were found from indirect comparisons of RCTs among the DOACs. For major bleeding, apixaban tended to be safer than rivaroxaban and dabigatran based on both direct and indirect comparisons (all p < 0.05; evidence quality: very low to moderate). Ranking probability analysis showed that apixaban had a high probability of being the best treatment in decreased risk of stroke/SE and major bleeding (80.30% and 91.30%, respectively). Likewise, apixaban was found to have the highest net clinical benefit (0.02, 95% CI: 0.014–0.029) and smallest NNTnet (48, 95% CI: 35–74). Conclusions: Apixaban appeared to have a favorable effectiveness-safety profile compared with the other DOACs in AF for stroke prevention, based on evidence from both direct and indirect comparisons. However, additional high-quality evidence is needed to support firm recommendations on clinical decision-making.

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European Journal of Epidemiology

Tập 36

793-812

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