Key result
Half-dose DOAC post-Watchman yields similar 1-year stroke and bleeding rates regardless of comorbidities.
Why the study?
Balancing thromboembolic and bleeding risks after LAAO is critical in older AF patients with age-associated comorbidities. This study evaluated the efficacy and bleeding risk of half-dose direct oral anticoagulants in patients aged >=75 years with versus without diabetes, uncontrolled hypertension, or heart failure.
Does a half-dose DOAC regimen after left atrial appendage occlusion prevent device-related thrombosis, stroke/TIA, and major bleeding similarly in elderly atrial fibrillation patients (≥75 years) with versus without cardiovascular comorbidities?
Cohort (n=779)
Does a half-dose DOAC regimen after left atrial appendage occlusion prevent device-related thrombosis, stroke/TIA, and major bleeding similarly in elderly atrial fibrillation patients (≥75 years) with versus without cardiovascular comorbidities?
Long-term half-dose DOAC therapy following Watchman LAAO is associated with low rates of stroke/TIA, major bleeding, and zero device-related thrombosis at 1 year in patients aged ≥75 years, regardless of the presence of diabetes, hypertension, or heart failure.
HD-DOAC post-LAAO linked to low stroke/TIA and bleeding rates in elderly AF patients irrespective of comorbidities; hypothesis-generating and requires randomized confirmation.
Introduction Antithrombotic therapy is used after left atrial appendage occlusion (LAAO) to prevent device-related thrombosis (DRT) that could lead to stroke or transient ischemic attack (TIA). Ageing in atrial fibrillation (AF) as well as many age-associated comorbidities are known risk factor for stroke. Moreover, bleeding risk is high in elderly patients on oral anticoagulation (OAC). Therefore, balancing the risk of bleeding and thromboembolic events is critical in older AF patients. Objective We aimed to assess the efficacy of half-dose of the direct oral anticoagulant (HD-DOAC) in preventing DRT and stroke while keeping the bleeding risk low in patients aged ≥75 years with vs without comorbidities such as diabetes, uncontrolled hypertension and heart failure. Methods Consecutive patients undergoing LAAO procedure were screened for those aged ≥75 years and these elderly patients were divided into two groups based on their comorbidity status. Group 1: No hypertension, diabetes or heart failure and Group 2: presence of ≥1 of the 3 above-mentioned conditions. All received HD-DOAC for 6 months after the LAAO procedure along with aspirin 81 mg followed by long-term HD-DOAC monotherapy. These patients were monitored for 1-year for DRT, Stroke/TIA and bleeding events. A total of 3 trans-esophageal echocardiography was performed at 1.5, 3 and 12-months post-procedure, to assess DRT. Results Of the 1636 AF patients undergoing LAAO procedure, 779 (47.6%) aged ≥75 years were included in this analysis (Group 1: 322 and Group 2: 457). In group 2, 214 (46.8%), 288 (63%) and 98 (21.4%) patients had diabetes, hypertension and heart failure respectively. HD-DOAC included apixaban 2.5 mg twice daily (n=568, 72.9%) or rivaroxaban 10 mg once a day (n=211, 27.1%). The median CHA2DS2-VASc score was 3 (IQR 2-4) and 4 (IQR: 3-6) in group 1 and 2 respectively. At 1 year, stroke/TIA were reported in 3 (0.93%) and 5 (1.09) patients in group 1 and 2 respectively (p=0.82). Major bleeding events were comparable across groups (Group 1: 2 (0.62%); Group 2: 4 (0.87%); p=0.69). No DRT was detected in either group. Conclusion After successful Watchman implantation, long-term HD-DOAC is safe and effective in reducing the risk of DRT, stroke/TIA and bleeding events in elderly patients regardless of their comorbidity status.
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Mohanty et al. (2026) conducted a cohort in Atrial fibrillation undergoing left atrial appendage occlusion (Watchman implantation) (n=779). Cardiovascular comorbidities (≥1 of diabetes, uncontrolled hypertension, or heart failure) on half-dose DOAC (apixaban 2.5 mg BID or rivaroxaban 10 mg QD) vs. No hypertension, diabetes, or heart failure on half-dose DOAC was evaluated on Stroke or transient ischemic attack (TIA) at 1 year (p=0.82). Half-dose DOAC after Watchman LAAO yielded similar 1-year rates of stroke/TIA (1.09% vs 0.93%; p=0.82), major bleeding (0.87% vs 0.62%; p=0.69), and DRT (0% vs 0%) in elderly patients with vs without comorbidities.
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