Updated Meta-Analysis of Left Atrial Appendage Closure Versus Oral Anticoagulation to Prevent Stroke in Atrial Fibrillation.
Prince K Pekyi-Boateng, Arankesh Mahadevan, Smith Kofi Frimpong et al.
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In 30 seconds
This systematic review and meta-analysis pooled six randomized controlled trials comparing percutaneous left atrial appendage closure (LAAC) with oral anticoagulation in 7028 patients with nonvalvular atrial fibrillation. Overall stroke rates were similar (odds ratio, 1.10 [95% CI, 0.78-1.56]), while ischemic stroke was more frequent with LAAC (odds ratio, 1.41 [95% CI, 1.07-1.86]) and nonprocedural bleeding less frequent (odds ratio, 0.58 [95% CI, 0.35-0.96]). The bleeding reduction reached the required information size; the ischemic-stroke finding did not.
Key findings
- Overall stroke rates were similar with LAAC and oral anticoagulation (odds ratio, 1.10 [95% CI, 0.78-1.56]).
- Ischemic stroke was more frequent with LAAC (odds ratio, 1.41 [95% CI, 1.07-1.86]), but the required information size was not reached.
- Nonprocedural bleeding was lower with LAAC (odds ratio, 0.58 [95% CI, 0.35-0.96]); this outcome reached a sufficient information size.
- The bleeding reduction was seen in standard-risk and postablation patients, but not in those at high bleeding risk.
Why it matters
The pooled evidence distinguishes bleeding outcomes from stroke prevention: LAAC was associated with less nonprocedural bleeding, but the analysis does not establish it as an equivalent substitute for anticoagulation in preventing stroke. This distinction is important when weighing procedural and medication-related risks, particularly because ischemic stroke was more frequent with LAAC in the pooled results.
What to keep in mind
The trials included varied populations, including high-bleeding-risk and postablation groups, and most participants were anticoagulation-eligible with low prior-stroke prevalence. The ischemic-stroke result did not reach the required information size.