New APS criteria show higher specificity but lower sensitivity

Antiphospholipid syndrome (APS) lacks systematic comparative evidence for the diagnostic performance of its three classification criteria, namely the 1999 Sapporo criteria, 2006 Revised criteria, and 2023 ACR criteria. This study aimed to comprehensively evaluate and compare the performance of the three criteria via a systematic review and network meta-analysis, providing an evidence-based basis for their clinical and research application. Following the PRISMA-NMA statement, we systematically searched PubMed, Embase, Cochrane Library, and Web of Science from inception to October 13, 2025, for studies evaluating the performance of the three APS classification criteria. Two reviewers independently performed study selection, data extraction, and quality assessment using the QUADAS-2 tool. Pairwise meta-analysis was conducted with Stata 15.0 to calculate the relative sensitivity and specificity. Network meta-analysis was performed using RStudio 4.3.0 to analyze sensitivity, specificity, DOR, and S index, and rank the diagnostic performance of the three criteria. Heterogeneity and publication bias were assessed using the I² index and Deeks’ funnel plot asymmetry test, respectively. A total of 7 eligible studies involving 8 research cohorts (2,214 APS patients, 3,908 subjects) were included. In the direct pairwise meta-analysis of the 2006 Revised criteria versus the 2023 ACR criteria, the 2023 ACR criteria showed significantly lower sensitivity (relative sensitivity 0.80; 95% CI: 0.72–0.89; P < 0.01) and significantly higher specificity (relative specificity 1.06; 95% CI: 1.05–1.08; P < 0.01) compared with the 2006 Revised criteria. Network meta-analysis indicated that the 2006 Revised criteria had the highest sensitivity (0.86, 95% CI: 0.83-0.88) and S index (1.92, 95% CI: 0.33-3.00) among the three; the 2023 ACR criteria had the highest specificity (0.98, 95% CI: 0.97-0.98) and DOR (114.66, 95% CI: 75.46-168.19). The 1999 Sapporo criteria have limited clinical application value due to relatively poor diagnostic performance. The 2006 Revised Sapporo criteria have advantages in diagnostic sensitivity and comprehensive diagnostic performance (S index). The 2023 ACR/EULAR criteria exhibit superior specificity, making it well-suited for clinical research and as an adjunctive diagnostic tool for patients with non-classical APS manifestations. https://www.crd.york.ac.uk/prospero/, identifier CRD420251074199.