Key result
Post-Watchman FLX DAPT is linked to ~1.5 percentage points lower major cardiovascular events vs. DOAC-based therapy.
Why the study?
The optimal antithrombotic therapy following left atrial appendage occlusion remains uncertain.
Does dual antiplatelet therapy reduce major adverse cardiovascular events, major bleeding, and device complications compared with direct oral anticoagulant-based therapy in high-risk patients undergoing left atrial appendage occlusion with Watchman FLX?
Cohort (n=2,817)
Yes
Does dual antiplatelet therapy reduce major adverse cardiovascular events, major bleeding, and device complications compared with direct oral anticoagulant-based therapy in high-risk patients undergoing left atrial appendage occlusion with Watchman FLX?
After Watchman FLX left atrial appendage occlusion, DAPT was associated with lower MACE and major bleeding compared to pooled DOAC-based therapy (driven primarily by comparisons against DOAC plus single antiplatelet therapy), supporting the need for randomized trials comparing DAPT with DOAC monotherapy.
Answers are grounded in this paper and cite their sources.
DAPT was associated with lower MACE after Watchman FLX; hypothesis-generating and should not yet change practice.
Background Optimal antithrombotic therapy after left atrial appendage occlusion remains uncertain. Methods We studied 2817 patients undergoing left atrial appendage occlusion at 8 hospitals from 2016 to 2023 using registry data linked to Medicare claims. Among 2448 Watchman FLX recipients, the primary exposure was time‐varying dual antiplatelet therapy (DAPT) versus pooled direct oral anticoagulant (DOAC)‐based therapy. Outcomes were major adverse cardiovascular events (MACE), major bleeding, and device complications. The primary instrumental‐variable analysis used operator FLX preference; overlap weighting was secondary and pairwise regimen comparisons exploratory. Results DAPT was associated with lower MACE (absolute risk difference [ARD], −1.5% [95% CI, −1.9% to −1.0%]; number needed to treat, 67) and major bleeding (ARD −1.6% [95% CI, −2.0% to −0.9%]; number needed to treat, 63) than pooled DOAC‐based therapy, without increased device complications. Overlap‐weighted associations with MACE and major bleeding were nonsignificant. In exploratory pairwise analyses, DAPT did not differ significantly from DOAC monotherapy for MACE or major bleeding; lower major bleeding was limited to DAPT versus DOAC plus single antiplatelet therapy (ARD, −0.6% [95% CI, −1.1% to −0.2%]; P =0.008). Most estimated benefit accrued within 6 months. Conclusions DAPT was associated with lower MACE and major bleeding than pooled DOAC‐based therapy after Watchman FLX implantation. The safety benefit was concentrated in the comparison with DOAC + single antiplatelet therapy, whereas DAPT and DOAC monotherapy did not clearly differ in either outcome. These findings support randomized trials comparing DAPT with DOAC monotherapy.
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Singh et al. (2026) conducted a cohort in High-risk patients undergoing left atrial appendage occlusion with Watchman FLX (n=2,817). Time-varying dual antiplatelet therapy (DAPT) vs. Pooled direct oral anticoagulant (DOAC)-based therapy was evaluated on Major adverse cardiovascular events (MACE), major bleeding, and device complications (ARD -1.5%, 95% CI -1.9% to -1.0%). Dual antiplatelet therapy after Watchman FLX was associated with lower major cardiovascular events and major bleeding than pooled DOAC-based therapy.
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