Log in to MyACC
LA Appendage Occlusion vs. Oral Anticoagulation in AF
Quick Takes
- Left atrial appendage occlusion (LAAO) was favorable over oral anticoagulation for patients with AF at high bleeding risk.
- LAAO was not consistently favorable over oral anticoagulation for patients with AF at high stroke risk.
- LAAO was more often favorable over warfarin therapy than DOAC therapy for patients with AF given differences in anticoagulation-related bleeding risk.
Study Questions:
What is the optimal strategy for stroke prevention in patients with atrial fibrillation (AF) conditional on their individual risk for ischemic stroke and bleeding?
Methods:
The authors performed a decision analysis using a Markov model based on published literature evidence. They explored the lifetime-horizon outcomes for men and women with nonvalvular AF who are considering left atrial appendage occlusion (LAAO) versus oral anticoagulation with warfarin or a direct oral anticoagulant (DOAC). The primary endpoint was quality-adjusted life-years as a measure of clinical benefit. Individual risks of stroke and bleeding were calculated across the risk spectrum using CHA2DS2-VASc and HAS-BLED scores for ischemic stroke and bleeding risk, respectively.
Results:
The combined risk of ischemic stroke and bleeding favored LAAO placement over oral anticoagulation for patients with higher bleeding risk. However, the benefit of LAAO over oral anticoagulation became less certain for patients at combined high risk of bleeding and ischemic stroke. The benefit for LAAO over warfarin was more pronounced than for LAAO versus DOAC comparison. For example, over 80% of simulated models favored LAAO over warfarin for a patient with a CHA2DS2-VASc score of 3 and a HAS-BLED score of 1-4, while those same simulated patients only favored LAAO over DOAC 60-80% of the time. Likewise, patients with a HAS-BLED score of 4 and CHA2DS2-VASc scores of 3-5 showed LAAO being favored over warfarin >80% of the time but favoring LAAO over DOAC only 40-80% of the time.
Conclusions:
The authors concluded that the benefits from LAAO over oral anticoagulation depend on the combination of both stroke and bleeding risk at the individual patient level and largely require low stroke risk for LAAO to be beneficial.
Perspective:
This elegant decision analysis study helps to understand the potential utility for LAAO as first-line therapy for stroke prevention in nonvalvular AF. Currently, most LAAO use is for patients who have a contraindication to ongoing anticoagulation therapy, such as those with prior bleeding events. However, ongoing studies are exploring the role of LAAO as a first-line therapy for stroke prevention in nonvalvular AF. This decision analysis, using data from published trials in high-bleed risk patients, demonstrates potential benefit of LAAO over oral anticoagulation for patients at low-moderate stroke risk (e.g., CHA2DS2-VASc scores ≤5). We eagerly await the prospective trials to better determine the potential role for LAAO as a first-line stroke prevention strategy for patients with nonvalvular AF.
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, Hemorrhage, Ischemic Stroke, Risk Assessment, Secondary Prevention, Stroke, Vascular Diseases, Warfarin
< Back to Listings
