Article Text

Download PDFPDF

Non-inferiority trials in cardiology: what clinicians need to know
  1. James T Leung1,
  2. Stephanie L Barnes2,
  3. Sidney T Lo3,
  4. Dominic Y Leung3
  1. 1 Cardiology, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
  2. 2 Neurology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
  3. 3 Cardiology, University of New South Wales, Liverpool Hospital, Liverpool, New South Wales, Australia
  1. Correspondence to Professor Dominic Y Leung, Cardiology, University of New South Wales, Liverpool Hospital, Sydney, NSW 2052, Australia; d.leung{at}


Clinical trials traditionally aim to show a new treatment is superior to placebo or standard treatment, that is, superiority trials. There is an increasing number of trials demonstrating a new treatment is non-inferior to standard treatment. The hypotheses, design and interpretation of non-inferiority trials are different to superiority trials. Non-inferiority trials are designed with the notion that the new treatment offers advantages over standard treatment in certain important aspects. The non-inferior margin is a predetermined margin of difference between the new and standard treatment that is considered acceptable or tolerable for the new treatment to be considered ‘similar’ or ‘not worse’. Both relative difference and absolute difference methods can be used to define the non-inferior margin. Sequential testing for non-inferiority and superiority is often performed. Non-inferiority trials may be necessary in situations where it is no longer ethical to test any new treatment against placebo. There are inherent assumptions in non-inferiority trials which may not be correct and which are not being tested. Successive non-inferiority trials may introduce less and less effective treatments even though these treatments may have been shown to be non-inferior. Furthermore, poor quality trials favour non-inferior results. Intention-to-treat analysis, the preferred way to analyse randomised trials, may favour non-inferiority. Both intention-to-treat and per-protocol analyses should be recommended in non-inferiority trials. Clinicians should be aware of the pitfalls of non-inferiority trials and not accept non-inferiority on face value. The focus should not be on the p values but on the effect size and confidence limits.

  • Biostatistics
  • Study design
  • Heart Disease

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from


  • Correction notice Since this article was first published online, figure 1 has been replaced. Further details on the changes can be found in the eletters section of the paper. These eletters can be found in the responses tab of the online article.

  • Contributors All authors have contributed to the writing, editing, revision and final approval of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.