Article Impact Level: HIGH Data Quality: STRONG Summary of Heart Rhythm, S1547527124000705. https://doi.org/10.1016/j.hrthm.2024.01.018 Dr. Michele Magnocavallo et al.
Points
- The study compared the safety and efficacy of left atrial appendage occlusion (LAAO) versus direct oral anticoagulants (DOACs) in atrial fibrillation (AF) patients with very high stroke risk (CHA2DS2-VASc score ≥ 5).
- Propensity score matching resulted in a matched population of 277 patients per group, focusing on a composite endpoint of cardiovascular death, thromboembolic events, and clinically relevant bleeding during follow-up.
- Among 554 very high-risk patients, the incidence of the composite endpoint was higher with DOACs compared to LAAO, with annualized clinically relevant bleeding risk notably higher with DOACs.
- LAAO demonstrated similar stroke prevention efficacy but a significantly lower risk of clinically relevant bleeding compared to DOACs. The clinical benefit of LAAO became significant after 18 months of follow-up.
- These findings suggest the potential long-term advantages of LAAO in very high-risk AF patients, emphasizing its role as a safe alternative to DOACs for thromboembolic prevention.
Summary
The study aimed to assess the safety and efficacy of left atrial appendage occlusion (LAAO) compared to direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) at a very high risk of stroke—data from a prospective multicenter database focused on patients with a CHA2DS2-VASc score of 5 or higher. Propensity score matching was employed to address covariate imbalances, resulting in a matched population of 277 patients per group. The primary endpoint encompassed a composite of cardiovascular death, thromboembolic events, and clinically relevant bleeding during the follow-up period.
The findings from the study, which included 554 very high-risk patients, revealed that the incidence of the composite endpoint was higher with DOACs compared to LAAO, with rates of 14.9/100 patient-years (py) and 9.4/100py, respectively (p=0.03). Furthermore, the annualized risk of clinically relevant bleeding was notably higher with DOACs (6.3% vs. 3.2%; p = 0.04), while the risk of thromboembolic events did not exhibit a significant difference between the two groups (4.1% vs. 3.2%; p = 0.63).
In conclusion, the study demonstrated that among high-risk patients with AF, LAAO exhibited comparable efficacy in stroke prevention but significantly lower risk of clinically relevant bleeding when compared to DOACs. Notably, the clinical benefit of LAAO became significant after 18 months of follow-up, highlighting the potential long-term advantages of this approach in very high-risk AF patients.
Link to the article: https://www.heartrhythmjournal.com/article/S1547-5271(24)00070-5/abstract
References Magnocavallo, M., Della Rocca, D. G., Vetta, G., Mohanty, S., Gianni, C., Polselli, M., Rossi, P., Parlavecchio, A., Fazia, M. V. L., Guarracini, F., De Vuono, F., Bisignani, A., Pannone, L., Raposeiras-Roubín, S., Lochy, S., Cauti, F. M., Burkhardt, J. D., Boveda, S., Sarkozy, A., … Natale, A. (2024). Lower rate of major bleeding in very high risk patients undergoing left atrial appendage occlusion: A propensity score–matched comparison with direct oral anticoagulation. Heart Rhythm, S1547527124000705. https://doi.org/10.1016/j.hrthm.2024.01.018
