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Direct oral anticoagulants for stroke prevention in patients with atrial fibrillation: A network meta-analysis of

Manyata Srivastava1, Annu Gulia1, Kamalesh Kumar Patel1

  • 1Clinical Research Unit, All India Institute of Medical Sciences, New Delhi, India.

Indian Heart Journal
|December 11, 2025
PubMed
Abstract

Insights

Direct oral anticoagulants (DOACs) are more effective and safer than vitamin K antagonists (VKAs) for preventing strokes in atrial fibrillation (AF) patients. Apixaban and dabigatran showed the best results, with apixaban being the most favorable option.

Area of Science:

  • Cardiology
  • Pharmacology
  • Clinical Research

Background:

  • Direct oral anticoagulants (DOACs) are increasingly favored over vitamin K antagonists (VKAs) for stroke prevention in patients with atrial fibrillation (AF).
  • This includes both valvular (VAF) and non-valvular (NVAF) atrial fibrillation.
  • Evaluating the comparative efficacy and safety of DOACs versus VKAs is crucial for optimizing patient care.

Purpose of the Study:

  • To conduct a network meta-analysis comparing the efficacy and safety of various DOACs against VKAs in AF patients.
  • To identify which DOACs offer the best outcomes for stroke prevention and bleeding risk reduction.

Main Methods:

  • A Bayesian network meta-analysis was performed.
  • Data from 43 randomized controlled trials (RCTs) were synthesized.
  • Odds ratios (ORs) with 95% credible intervals (CrIs) were estimated to compare treatment effects.

Main Results:

  • Dabigatran showed the greatest reduction in ischemic stroke/systemic embolism (OR 0.77, 95% CrI 0.68-0.87), followed by apixaban (OR 0.81, 0.73-0.91).
  • All evaluated DOACs demonstrated a reduced risk of hemorrhagic stroke compared to VKAs.
  • The analysis included data from 30 VAF and 13 NVAF trials.

Conclusions:

  • DOACs, specifically apixaban and dabigatran, exhibit superior efficacy and safety profiles compared to VKAs for AF patients.
  • Apixaban was identified as the most favorable overall option based on the analyzed data.
  • Findings derived from indirect comparisons warrant cautious interpretation; direct head-to-head trials are needed for definitive conclusions.
Keywords:
Atrial fibrillationDirect oral anticoagulantsMajor bleedingNetwork meta-AnalysisStroke preventionVitamin K antagonists

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