Comparative effectiveness of interventions for stroke prevention in atrial fibrillation: A network meta-analysis

Background the goal of this study was to compare the safety and effectiveness of individual antiembolic interventions in nonvalvular atrial fibrillation (af): novel oral anticoagulants (noacs) (apixaban,dabigatran,edoxaban,and rivaroxaban); vitamin k antagonists (vka); aspirin; and the watchman device. methods and results a network meta-analysis of randomized,clinical trials (rcts) was performed. rcts that included patients with prosthetic cardiac valves or mitral stenosis,mean or median follow-up <6 months,<200 participants,without published report in english language,and noac phase ii studies were excluded. the placebo/control arm received either placebo or no treatment. the primary efficacy outcome was the combination of stroke (of any type) and systemic embolism. all-cause mortality served as a secondary efficacy outcome. the primary safety outcome was the combination of major extracranial bleeding and intracranial hemorrhage. a total of 21 rcts (96 017 nonvalvular af patients; median age,72 years; 65% males; median follow-up,1.7 years) were included. in comparison to placebo/control,use of aspirin (odds ratio [or],0.75 [95% ci,0.60-0.95]),vka (0.38 [0.29-0.49]),apixaban (0.31 [0.22-0.45]),dabigatran (0.29 [0.20-0.43]),edoxaban (0.38 [0.26-0.54]),rivaroxaban (0.27 [0.18-0.42]),and the watchman device (0.36 [0.16-0.80]) significantly reduced the risk of any stroke or systemic embolism in nonvalvular af patients,as well as all-cause mortality (aspirin: or,0.82 [0.68-0.99]; vka: 0.69 [0.57-0.85]; apixaban: 0.62 [0.50-0.78]; dabigatran: 0.62 [0.50-0.78]; edoxaban: 0.62 [0.50-0.77]; rivaroxaban: 0.58 [0.44-0.77]; and the watchman device: 0.47 [0.25-0.88]). apixaban (0.89 [0.80-0.99]),dabigatran (0.90 [0.82-0.99]),and edoxaban (0.89 [0.82-0.96]) reduced risk of allcause death as compared to vka. conclusions--the entire spectrum of therapy to prevent thromboembolism in nonvalvular af significantly reduced stroke/ systemic embolism events and mortality. © 2016 the authors.