October 13, 2026Journal of Cardiovascular Electrophysiology
Left Atrial Appendage Closure Versus Oral Anticoagulation for Prevention of Stroke or Systemic Embolism in Patients With Atrial Fibrillation: An Updated Meta‐Analysis of 7004 Patients Across Six Randomized Trials
Key result
LAAC shows no benefit over oral anticoagulation for stroke or systemic embolism.
- RR 1.10
- 95% CI 0.87-1.39
- P=0.42
- n=7,004
Why the study?
The efficacy and safety of left atrial appendage closure compared with oral anticoagulants for stroke prevention in atrial fibrillation patients remain uncertain.
Does left atrial appendage closure prevent stroke or systemic embolism compared to oral anticoagulation in patients with atrial fibrillation?
Key Points
- To evaluate the efficacy and safety of left atrial appendage closure compared with oral anticoagulation for stroke and systemic embolism prevention in patients with atrial fibrillation.
- Systematic review and meta-analysis of 6 randomized controlled trials involving 7,004 patients with atrial fibrillation identified across three databases up to April 7, 2026.
- Pooled risk ratios (RRs) and 95% confidence intervals (CIs) calculated via a random-effects model comparing left atrial appendage closure with oral anticoagulants, with sensitivity analyses for direct oral anticoagulants.
- Risk of stroke or systemic embolism did not differ significantly between left atrial appendage closure and oral anticoagulants (RR: 1.10 [95% CI: 0.87–1.39]; p = 0.42), but ischemic events significantly increased with closure (RR: 1.41 [95% CI: 1.07–1.85]; p = 0.02).
- Left atrial appendage closure showed a similar rate of major bleeding (RR: 0.92 [95% CI: 0.77–1.09]) alongside a significant reduction in non-procedural bleeding (RR: 0.61 [95% CI: 0.52–0.73]; p < 0.001).
- No significant differences occurred for all-cause mortality (RR: 0.94 [95% CI: 0.81–1.09]), cardiovascular mortality (RR: 0.91 [95% CI: 0.69–1.21]), non-cardiovascular mortality (RR: 0.91 [95% CI: 0.75–1.12]), or hemorrhagic stroke (RR: 0.58 [95% CI: 0.29–1.17]).
Study Design
Type
Meta-Analysis (n=7,004)
Structured PICO
Does left atrial appendage closure prevent stroke or systemic embolism compared to oral anticoagulation in patients with atrial fibrillation?
P
Population
7,004 patients with atrial fibrillation from six randomized trials comparing left atrial appendage closure with oral anticoagulation.
I
Intervention
Left atrial appendage closure (LAAC)
C
Comparator
Oral anticoagulation (OAC)
O
Outcome
Stroke or systemic embolism (SSE)composite
Main Result
Relative Risk: 1.1 (95% CI 0.87–1.39)
p-value: p=0.42
LAAC offers comparable overall prevention of stroke/systemic embolism and major bleeding compared to oral anticoagulation, with reduced non-procedural bleeding at the cost of a higher risk of ischemic events.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“In patients with AF at moderate to high risk of stroke, catheter-based LAAC resulted in similar rates of overall stroke and major bleeding compared with oral anticoagulation but was associated with a significantly higher risk of ischaemic stroke and a lower risk of non-procedure-related major bleeding. These findings suggest that the net clinical benefit of catheter-based LAAC relative to oral anticoagulation remains uncertain and do not support its routine use as a first-line strategy for stroke prevention in this population.”
“While I am biased by being an author on this paper, I see the data as strengthening the case against using LAAC as a substitute for oral anticoagulation. There is a clear signal of higher rates of ischemic stroke. From a Bayesian point of view, the probability of reaching non-inferiority for stroke and systemic embolism using a lax measure of 1.4 is less than 50%.”
AGAndrew GoldsweigCardiovascular medicine, University of Massachusetts-Baystate
“While the present analysis is congruent to other recent meta-analyses in identifying slightly higher ischemic stroke and lower nonprocedural bleeding rates, Rai et al suggest the novel findings that all-cause stroke may be higher with LAAO (70% chance) but that major bleeding may be lower with LAAO (86% chance).”
Implication
LAAC offers comparable stroke prevention to OAC in AF; confirms similar efficacy across pooled randomized trials.
Abstract
Introduction Left atrial appendage closure (LAAC) is an emerging alternative for stroke prevention in patients with atrial fibrillation (AF) who are unsuitable for long‐term oral anticoagulants (OACs). However, its efficacy and safety relative to OACs remain uncertain. Methods Three databases were searched up to April 7, 2026, for randomized controlled trials comparing LAAC with OAC in patients with AF. Risk ratios with 95% confidence intervals were pooled using a random‐effects model. Results Six RCTs ( n = 7004 patients) were analyzed. The risk of stroke or systemic embolism (SSE) did not differ significantly between the LAAC and OAC groups (RR: 1.10 [0.87–1.39]; p = 0.42). The risk of ischemic SSE was significantly increased with LAAC (RR: 1.41 [1.07–1.85]; p = 0.02) compared with OAC. No significant differences were observed in all‐cause mortality (RR: 0.94 [0.81–1.09]), cardiovascular mortality (RR: 0.91 [0.69–1.21]), non‐cardiovascular mortality (RR: 0.91 [0.75–1.12]), or hemorrhagic stroke (RR: 0.58 [0.29–1.17]). LAAC was associated with a similar risk of overall major bleeding (RR: 0.92 [0.77–1.09]) and low risk of non‐procedural bleeding (RR: 0.61 [0.52–0.73]; p < 0.001) compared with OAC. Upon sensitivity analysis comparing LAAC with DOACs, the findings remained consistent across most clinical outcomes. Conclusion LAAC demonstrates comparable risks of SSE and major bleeding to OACs, but is associated with a higher risk of ischemic SSE and reduced non‐procedural bleeding, supporting its use in selected patients at high risk for long‐term bleeding while emphasizing individualized shared decision‐making.
Discussion
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Cite This Study
Ahmed 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 Stroke or systemic embolism (SSE) (RR 1.10, 95% CI 0.87-1.39, p=0.42). Left atrial appendage closure showed no significant difference in the risk of stroke or systemic embolism compared with oral anticoagulation (RR 1.10; 95% CI 0.87-1.39; p=0.42).