October 30, 2019JAMA Network OpenOpen Access

Clinical Outcomes of Mortality, Readmissions, and Ischemic Stroke Among Medicare Patients Undergoing Left Atrial Appendage Closure via Implanted Device

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Why the study?

Does Left Atrial Appendage Closure via implanted device reduce ischemic stroke readmissions and mortality in older Medicare patients with atrial fibrillation who are ineligible for warfarin?

Structured PICO

Does Left Atrial Appendage Closure via implanted device reduce ischemic stroke readmissions and mortality in older Medicare patients with atrial fibrillation who are ineligible for warfarin?

Population

Medicare patients older than 65 years with atrial fibrillation who are ineligible to receive warfarin and have a high number of comorbidities

Intervention

Left Atrial Appendage Closure (LAAC) via implanted device

Comparator

Expected rates based on CHA2DS2-VASc scores in the absence of anticoagulation therapy (historical/expected comparator)

Outcome

Readmission rates for ischemic strokes at 6 months and mortality at 1 yearhard clinical

In a real-world Medicare population of older, sicker patients with atrial fibrillation ineligible for warfarin, LAAC yielded lower-than-expected 6-month ischemic stroke readmissions but higher 1-year mortality compared to historical RCTs.

Implication

LAAC may lower stroke readmissions in ineligible AF patients; leaves open excess mortality versus RCTs in real-world elderly cohorts.

Abstract

In this cohort study of patients older than 65 years with atrial fibrillation who underwent LAAC with an implanted device, readmission rates for ischemic strokes over the course of 6 months were lower than expected given the patients' CHA2DS2-VASc scores in the absence of anticoagulation therapy. Mortality at 1 year was higher than that reported in previous randomized clinical trials, likely because the patients in the present study were older, had a higher number of comorbidities, and were ineligible to receive warfarin.