Key result
LAAO linked to ~52% fewer major events vs DOACs in AF patients with prior stroke.
Why the study?
Clinical outcomes associated with left atrial appendage occlusion versus direct oral anticoagulation in patients with AF and prior ischemic stroke had not been determined.
Does left atrial appendage occlusion reduce the composite of ischemic stroke, major bleeding, or all-cause mortality compared to direct oral anticoagulation in patients with atrial fibrillation and prior ischemic stroke?
Cohort (n=587)
Yes
Does left atrial appendage occlusion reduce the composite of ischemic stroke, major bleeding, or all-cause mortality compared to direct oral anticoagulation in patients with atrial fibrillation and prior ischemic stroke?
Effect estimate: HR 0.48 (95% CI 0.35-0.65)
Absolute Event Rate: 12.4% vs 26.9%
p-value: p=<0.001
In patients with atrial fibrillation and prior ischemic stroke, LAAO was associated with a significantly lower risk of the composite of stroke, major bleeding, and all-cause mortality compared to DOAC, driven primarily by reductions in major bleeding and mortality.
LAAO was associated with lower composite risk versus DOAC in AF with prior stroke; leaves open confirmation by randomized trials before practice change.
BACKGROUND: This propensity-score matched study investigated clinical outcomes associated with left atrial appendage occlusion (LAAO) versus direct oral anticoagulation (DOAC) in patients with AF and prior ischemic stroke. METHODS: -VASc and HAS-BLED scores, with a 1:2 ratio and using Greedy 5:1 digit matching with replacement. The analysis included 2-years follow-up, with a primary composite outcome of ischemic stroke, major bleeding (BARC ≥ 3) or all-cause mortality. RESULTS: -VASc scores were 5.26 (1.42) and 5.40 (1.31) and HAS-BLED scores were 3.95 (0.91) and 4.03 (0.96), for the LAAO and DOAC group, respectively. Total number of primary composite outcome events were 61 (12.4 events/100 patient-years) and 117 (26.9 events/100 patient-years) in the LAAO and DOAC group, respectively. Risk of the primary composite outcome was significantly lower in the LAAO group, hazard rate ratio [HR] 0.48 (95% CI: 0.35-0.65). Ischemic stroke risk was comparable, HR 0.71 (95% CI: 0.34-1.45), while risk of major bleeding, HR 0.41 (95% CI: 0.25-0.67), and all-cause mortality, HR 0.48 (95% CI: 0.32-0.71), were significantly lower with LAAO. Cardiovascular mortality did not differ statistically between the LAAO and DOAC group, HR 0.75 (95% CI: 0.39-1.42). Results were consistent across sensitivity analyses. CONCLUSION: This study indicated significantly lower risk of the composite outcome of stroke, major bleeding and all-cause mortality with LAAO therapy compared to DOAC, in patients with AF and prior stroke. The stroke prevention effectiveness appeared similar, with a significantly lower risk of major bleeding events with LAAO. The suggested clinical benefit of LAAO over DOAC require confirmation in the ongoing randomized OCCLUSION-AF trial.
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Korsholm et al. (2022) conducted a cohort in Atrial fibrillation and prior ischemic stroke (n=587). Left atrial appendage occlusion (LAAO) vs. Direct oral anticoagulation (DOAC) was evaluated on Composite of ischemic stroke, systemic embolism, major bleeding, or all-cause mortality (HR 0.48, 95% CI 0.35-0.65, p=<0.001). Left atrial appendage occlusion reduced the composite of ischemic stroke, major bleeding, and all-cause mortality (HR 0.48) compared to direct oral anticoagulation in AF patients with prior stroke.
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