Key result
LAAC shows no benefit over OAC for any stroke, increasing ischemic stroke but reducing nonprocedural bleeding.
Why the study?
Randomized controlled trials of LAAC versus OAC have primarily focused on composite end points, potentially obscuring differences in individual clinical outcomes.
Does left atrial appendage closure reduce stroke and major bleeding compared to oral anticoagulation in adults with atrial fibrillation?
Meta-Analysis (n=7,004)
Does left atrial appendage closure reduce stroke and major bleeding compared to oral anticoagulation in adults with atrial fibrillation?
Relative Risk: 1.08 (95% CI 0.82–1.42)
p-value: p=0.60
In patients with atrial fibrillation, left atrial appendage closure increases the risk of ischemic stroke but decreases nonprocedural major bleeding compared to oral anticoagulation, highlighting the need for individualized risk-benefit assessment.
LAAC raises ischemic stroke risk while halving nonprocedural bleeding versus OAC; challenges composite-endpoint reliance and extends calls for individual-outcome RCTs.
BACKGROUND: Left atrial appendage closure (LAAC) is an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation, but randomized controlled trials have primarily focused on composite end points, potentially obscuring differences in individual clinical outcomes. We compared the efficacy and safety of LAAC versus OAC with an emphasis on individual clinical outcomes. METHODS: A systematic review and meta-analysis of randomized controlled trials comparing LAAC with OAC in adults with atrial fibrillation was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases were searched from January 2000 to March 2026. The primary efficacy end point was any stroke, and the primary safety end point was major bleeding. Risk ratios (RRs) with 95% CIs were pooled using a random-effects model. RESULTS: Six randomized controlled trials comprising 7004 patients (3681 LAAC; 3323 OAC) were included. LAAC was associated with a higher risk of ischemic stroke (RR, 1.41 [95% CI, 1.04–1.91]; P =0.03; 3.2% versus 2.1%), without a significant difference in any stroke (RR, 1.08 [95% CI, 0.82–1.42]; P =0.60) or the composite of stroke, systemic embolism, or death (RR, 0.99 [95% CI, 0.77–1.29]; P =0.96). Cardiovascular mortality (RR, 0.88; P =0.40) and all-cause mortality (RR, 0.92; P =0.36) were similar between groups. Major bleeding, including procedural events, did not differ significantly (RR, 0.93; P =0.40), although LAAC was associated with a significantly lower risk of nonprocedural major bleeding (RR, 0.57 [95% CI, 0.43–0.77]; P <0.01; 6.2% versus 10.7%). CONCLUSIONS: In patients with atrial fibrillation, LAAC is associated with a higher risk of ischemic stroke, but lower risk of nonprocedural major bleeding compared with OAC, with no significant differences in composite thromboembolic outcomes or mortality, underscoring the importance of individualized risk-benefit assessment in stroke prevention strategies.
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Rao et al. (2026) conducted a meta-analysis in atrial fibrillation (n=7,004). Left atrial appendage closure (LAAC) vs. Oral anticoagulation (OAC) was evaluated on any stroke (RR 1.08, 95% CI 0.82-1.42, p=0.60). Left atrial appendage closure showed no significant difference in any stroke compared with OAC (RR 1.08; 95% CI 0.82-1.42; P=0.60), but increased ischemic stroke and reduced nonprocedural bleeding.