Less Severe Strokes With LAA Closure vs DOAC in AF?

TOPLINE:

Left atrial appendage closure was associated with about half as many disabling or fatal strokes and lower mortality after a stroke compared with dual oral anticoagulant therapy in patients with atrial fibrillation (AF), new observational research shows.

METHODOLOGY:

The retrospective registry analysis included 447 adult patients with nonvalvular AF, mean age 74 years, who were hospitalized with an ischemic stroke (IS), 322 of whom were receiving direct oral anticoagulant (DOAC) therapy, mostly (84%) apixaban or rivaroxaban, and 125 were treated with left atrial appendage closure (LAAC), almost all (97%) with Watchman or Watchman-FLX devices.
All patients received standard stroke care, monitoring, and treatment as well as physical therapy/rehabilitation.
For the primary outcome, researchers used the modified Rankin Scale (mRS) to determine disabling (mRS score of 3-5) and fatal (mRS score of 6) strokes at discharge and at 3 months.
The study adjusted for age, smoking, paroxysmal AF, prior major bleeding, prior hemorrhagic stroke, medication adherence, and other risk factors.

TAKEAWAY:

The incidence of disabling or fatal IS was significantly lower with LAAC vs with DOAC at discharge (38.3% vs 70.3%; P < .001) and at 3 months (33.3% vs 56.2%; P < .001), even though the LAAC group had more baseline comorbidity, for example, older age, more smokers, and more prior major bleeding.
There was no significant difference in mortality between groups during hospitalization, but at 3 months, mortality was lower in the LAAC group (14.7% vs 32.1%; P = .002).
Multivariate linear regression analysis showed LAAC independently predicted more favorable mRS at discharge (2.8) and 3 months (1.4) (both P < .001) and was associated with less all-cause death at 3 months (odds ratio [OR], 0.28; 95% CI, 0.12 - 0.64; P = .002).
Sensitivity analyses, including those that excluded the 14.4% of LAAC patients who also received DOAC therapy, patients who got reduced dose DOACs, and nonadherent patients, yielded nearly identical outcomes to the full cohort analysis.

IN PRACTICE:

"Despite a higher baseline risk profile, patients treated with LAAC who developed IS had better outcomes than those receiving DOAC prophylaxis," the authors conclude, adding that several ongoing prospective trials could, "shed light on the mechanism(s) responsible for differences in stroke severity."

SOURCE:

The study was conducted by Mohit K. Turagam, MD, Icahn School of Medicine at Mount Sinai, New York, NY, and colleagues. It was published online on November 22, 2023 in JACC: Clinical Electrophysiology.

LIMITATIONS:

Despite sensitivity analyses and adjustment for risk factors, selection bias, missing data, and other confounding factors could have affected outcomes. The study didn't evaluate recurrent IS or type and intensity of rehabilitation on outcomes. Lack of imaging data comparing stroke infarct size and volume limits understanding of exact mechanism driving higher stroke severity with DOACs. Because patients who died before reaching hospital weren't captured in the registry, the actual mortality may be higher than reported.

DISCLOSURES:

Turagam has served as a consultant for Biosense Webster and Sanofi; see paper for disclosures of other authors.

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