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Ischemic Stroke Severity After LAAC vs. NOAC
Quick Takes
- Ischemic strokes from atrial fibrillation (AF) tend to be more disabling than strokes from other causes. Both left atrial appendage closure (LAAC) and direct oral anticoagulation (NOAC) are effective in preventing ischemic stroke in patients with AF.
- It is unknown whether LAAC or NOAC is more effective in reducing disabling or fatal ischemic strokes that occur despite prophylaxis in patients with AF.
- In this registry-based study, ischemic strokes in AF patients status/post LAAC were less likely to be disabling or fatal at the time of hospital discharge and at 3 months compared to the ischemic strokes of AF patients on NOAC.
Study Questions:
Is there a difference in the severity of ischemic stroke in patients with atrial fibrillation (AF) who have undergone left atrial appendage closure (LAAC) versus patients on direct oral anticoagulation (NOAC)?
Methods:
This is a retrospective analysis of prospective and retrospective registries from eight centers in the United States and Europe enrolling consecutive patients who underwent LAAC and who were subsequently hospitalized with ischemic stroke and, for the comparator arm, contemporaneous consecutive patients with AF on NOAC who were hospitalized with ischemic stroke. Modified Rankin scale (mRS) scores were collected on admission, at discharge, and at 3 months after stroke presentation. The primary outcome was disabling or fatal stroke defined as a mRS score >2 at discharge and at 3 months post-stroke.
Results:
The ischemic stroke patients in the LAAC group (n = 125) were older and more often had a history of smoking, prior major bleeding, prior transient ischemic attack, and/or prior hemorrhagic stroke than the ischemic stroke patients in the NOAC group (n = 322). CHA2DS2-VASc scores and history of prior ischemic stroke were similar in the two groups. In the LAAC group, 14.4% were also on a NOAC. There was no difference in mRS score at admission nor receipt of endovascular therapy or tPA between the two groups. At discharge, 70.3% of the NOAC group compared to 38.3% of the LAAC group had a disabling or fatal stroke (p < 0.001). At 3 months, 56.2% of the NOAC group compared to 33.3% of the LAAC group had a disabling or fatal stroke. Hemorrhagic transformation was observed more frequently in the NOAC group (22.7%) than in the LAAC group (9.6%).
Conclusions:
In this registry-based study, AF patients status/post LAAC who developed ischemic stroke had better functional outcomes and lower mortality at discharge and at 3 months post-stroke than AF patients on NOAC who developed ischemic stroke.
Perspective:
Because this is not a randomized trial, selection bias may be at play (although if anything, the LAAC group appeared ‘sicker’ than the NOAC group by baseline characteristics). It is also worth noting that 10% of the LAAC group was lost to follow-up at 3 months compared to 57% of the NOAC group. Overall, though, this is a compelling study, despite its limitations. The reason for the stronger association of LAAC with lower ‘breakthrough’ stroke disability and fatality is unclear but may be due to lower thromboembolic burden (i.e., smaller thrombi) or reduced risk of hemorrhagic transformation or other bleeding. It would be reasonable for a clinician to consider this association as one factor in favor of LAAC when deciding whether LAAC or NOAC therapy is the best option for a given patient.
Clinical Topics: Anticoagulation Management, Vascular Medicine, Anticoagulation Management and Atrial Fibrillation
Keywords: Anticoagulants, Atrial Appendage, Ischemic Stroke
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