Role of left atrial appendage occlusion versus direct oral anticoagulants in elderly patients (80 years) with atrial fibrillation: a retrospective cohort analysis

Abstract Background Elderly patients with atrial fibrillation (AF) are at increased risk for thromboembolism and bleeding. Although direct oral anticoagulants (DOACs) are widely used, their associated bleeding risks may outweigh their benefits in frail populations. Left atrial appendage occlusion (LAAO) offers an alternative, yet limited data exist comparing its safety and efficacy with DOACs in patients over 80 years of age. Methods This retrospective cohort study utilized data from the global TriNetX Collaborative Network to assess outcomes in AF patients aged 80 years or older treated with either LAAO or DOACs from January 1, 2015, to June 30, 2023. Primary outcomes included stroke and systemic thromboembolism, while secondary outcomes encompassed bleeding events, rehospitalization, and major adverse cardiac events (MACE). Baseline characteristics were balanced using propensity score matching, and outcomes were compared between the treatment groups. Results After matching, 3,670 patients who underwent LAAO and 3,662 patients treated with DOACs were included, with a mean age of 85.1 years and 57.5% male representation in both groups. The median follow-up was 392.5 days for the LAAO group and 477 days for the DOAC group, with mean follow-up durations of 680.97 days and 780.15 days, respectively. At six months, LAAO was associated with a reduction in stroke incidence (6.09% vs. 9.26%, p 0.0001), systemic thromboembolism (0.87% vs. 2.95%, p 0.0001), and rehospitalization (30.97% vs. 35.01%, p = 0.0002), but an increase in gastrointestinal (GI) bleeding (6.17% vs. 2.32%, p 0.0001). Rates of MACE were similar between the two groups (24.52% vs. 25.70%, p = 0.2466). In long-term follow-up, LAAO continued to show benefits, with lower risks of stroke (10.57% vs. 14.72%, p 0.0001), systemic thromboembolism (1.99% vs. 4.32%, p 0.0001), MACE (35.25% vs. 38.17%, p = 0.0095), and rehospitalization (45.17% vs. 54.29%, p 0.0001). However, GI bleeding remained higher with LAAO (8.68% vs. 5.60%, p 0.0001), while rates of intracranial hemorrhage were similar between the groups (0.66% vs. 0.38%, p = 0.1039). Conclusions In elderly AF patients, LAAO was associated with significant reductions in stroke, systemic thromboembolism, and rehospitalization risks compared to DOACs during both short- and long-term follow-up. However, LAAO was linked to an increased risk of GI bleeding, while MACE rates remained comparable.