Antiplatelet vs. Anticoagulant Therapy After LAAO

May 21, 2020
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Authors:
Osman M, Busu T, Osman K, et al.
Citation:
Short-Term Antiplatelet Versus Anticoagulant Therapy After Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol 2020;6:494-506.
Summary By:
Mollie McDermott, MD, MS

Quick Takes

  • In clinical practice, it is often desirable to use short-term APT rather than protocol-concordant short-term OAC after LAAO given that these patients often have a history of bleeding complications.
  • In this meta-analysis of both single-arm and comparator studies, patients who received APT rather than OAC after LAAO had similar rates of all-cause stroke, major bleeding, device-related thrombus, and all-cause mortality.
  • The results of this meta-analysis support the need for a randomized controlled trial to prospectively evaluate the safety of APT versus OAC after LAAO.

Study Questions:

After left atrial appendage occlusion (LAAO), are clinical outcomes better with short-term oral anticoagulation (OAC) or short-term antiplatelet therapy (APT)?

Methods:

This is a systematic review and meta-analysis of all studies published through May 2019 using OAC or APT after LAAO (with Watchman, Amplatzer Cardiac Plug, or Amulet). Both comparative studies and single-arm studies were included. Outcomes of interest included all-cause stroke, major bleeding, device-related thrombus, and all-cause mortality. Included studies had to report at least one of these outcomes of interest.

Results:

Eighty-three studies involving 12,326 patients were included in the analysis. No difference was observed between the APT and OAC groups in all-cause stroke, major bleeding, device-related thrombus, or all-cause mortality. When the analysis was limited to comparative studies (excluding single-arm studies), again no difference was observed in the outcomes of interest. No interaction by device type (Watchman or Amulet) was observed.

Conclusions:

Patients who received short-term APT rather than short-term OAC after LAAO had similar rates of all-cause stroke, major bleeding, device-related thrombus, and all-cause mortality.

Perspective:

LAAO is used to lower the risk of ischemic stroke in patients with atrial fibrillation. Typical post-closure protocols call for short-term OAC followed by APT. In clinical practice, many patients considered for LAAO have a higher risk of bleeding with OAC and would be preferably placed on APT post-closure. The results of this meta-analysis support the safety of APT post-LAAO and suggest the need for a randomized controlled trial to prospectively evaluate the safety of APT versus OAC after LAAO. A well-conducted trial showing equivalence of the two therapies in safety and efficacy would be sure to change clinical practice.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Brain Ischemia, Coronary Occlusion, Hemorrhage, Outcome Assessment, Health Care, Platelet Aggregation Inhibitors, Secondary Prevention, Stroke, Thrombosis, Vascular Diseases


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