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

BACKGROUND: Direct oral anticoagulants (DOACs) are increasingly preferred over vitamin K antagonists (VKAs) for stroke prevention in atrial fibrillation (AF), including valvular (VAF) and non-valvular (NVAF). This network meta-analysis aimed to evaluate and compare the efficacy and safety of different DOACs versus VKAs in patients with AF. METHODS: A Bayesian network meta-analysis was conducted to estimate odds ratios (ORs) with 95 % credible intervals (CrIs). RESULTS: 43 RCTs were included (30 VAF, 13 NVAF). Dabigatran (OR 0.77, 95 % CrI 0.68-0.87) demonstrated the strongest reduction in ischemic stroke/systemic embolism, followed by apixaban (0.81, 0.73-0.91). All DOACs were associated with reduced risk of hemorrhagic stroke. CONCLUSION: DOACs, particularly apixaban and dabigatran, showed superior efficacy and safety compared with VKAs, with apixaban emerging as the most favorable overall option. However, these findings are derived from indirect rather than direct head-to-head comparisons among DOACs and VKAs and should therefore be interpreted with caution.