Advancing The Therapeutic Landscape Of Direct Oral Anticoagulants: A Systematic Review And Meta-Analysis Of Efficacy, Safety, And Cost-Effectiveness In Coronary Artery Disease Management

Abstract

Direct oral anticoagulants (DOACs) have revolutionized anticoagulation therapy, offering a favorable safety profile and improved patient adherence over traditional vitamin K antagonists like warfarin. Nevertheless, their long term efficacy, safety, and cost effectiveness in the treatment of coronary artery disease (CAD) needs to be determined by systematic reviews and meta analysis. Aim This systematic review and meta analysis objective is to compare the outcome efficacy and safety and economic consequence of DOACs (apixaban, dabigatran vs warfarin) in CAD patients. The purpose of the study is to offer an evidence-based rationale for personalized anticoagulation strategies and healthcare policy recommendations. Study Design: A thorough literature search was done on randomized controlled trails (RCTs) and observational studies carried out between 2010 and 2024 on PubMed, Scopus, Web of Science, and Cochrane Library. Included in the studies were studies comparing warfarin, apixaban and dabigatran in CAD patients. Thrombotic events, major bleeding incidents, mortality and patient adherence were the main outcomes examined. The I² statistic was used to assess statistical heterogeneity, pooled risk ratios (RR) with 95% confidence intervals CI calculated using a random effect model and data were combined using inverse variance weights. Results: Twenty five studies (N= 38 500 patients) were included. Compared to warfarin, the use of DOACs was significantly lower in risk of major bleeding events (RR: 0.58; 95% CI: 0.47–0.72; p<0.001). A total of 91% adherence was demonstrated with apixaban and this disease event rate was lower than that of placebo and enoxaparin (RR: 0.72; 95% CI: 0.61–0.85). Apixaban was shown to be the most cost effective regarding the cost per quality adjusted life year (QALY). Our findings were sensitive to these results. Conclusion:ANOVA meta-analysis confirmed that DOACs, and apixaban in particular, have better safety and adherence in the management of CAD. These findings suggest that it is appropriate to shift to personalized anticoagulation strategies and policy pertaining the adoption of DOACS based on patient risk stratification. It should be integrated to future research of pharmacogenomics and real world data to improve clinical decision making