An updated meta-analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation
The availability of direct oral anticoagulants (DOACs) with known lower bleeding risk compared with warfarin have raised questions about the role of left atrial appendage closure (LAAC). We aimed to perform a meta-analysis to compare the clinical outcomes for LAAC versus DOACs. All studies directly...
| Main Authors: | , , , , , , , , |
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| Format: | Journal Article |
| Language: | English |
| Published: |
2023
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| Online Access: | https://hdl.handle.net/10356/169956 |
| _version_ | 1826129774278344704 |
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| author | Jiang, Haowen Koh, Tian Hai Vengkat, Vijay Fei, Gao Ding, Zee Pin Ewe, See Hooi Jappar, Ignasius Lim, Soo Teik Yap, Jonathan |
| author2 | Lee Kong Chian School of Medicine (LKCMedicine) |
| author_facet | Lee Kong Chian School of Medicine (LKCMedicine) Jiang, Haowen Koh, Tian Hai Vengkat, Vijay Fei, Gao Ding, Zee Pin Ewe, See Hooi Jappar, Ignasius Lim, Soo Teik Yap, Jonathan |
| author_sort | Jiang, Haowen |
| collection | NTU |
| description | The availability of direct oral anticoagulants (DOACs) with known lower bleeding risk compared with warfarin have raised questions about the role of left atrial appendage closure (LAAC). We aimed to perform a meta-analysis to compare the clinical outcomes for LAAC versus DOACs. All studies directly comparing LAAC with DOACs up to January 2023 were included. The outcomes studied included the combined major adverse cardiovascular (CV) events outcomes, ischemic stroke and thromboembolic events, major bleeding, CV mortality, and all-cause mortality. Hazard ratios (HRs) and their 95% confidence interval were extracted or estimated from the data and pooled together with a random-effects model. A total of 7 studies (1 randomized controlled trial, 6 propensity-matched observational studies) were finally included, with a pooled population of 4,383 patients who underwent LAAC and 4,554 patients on DOACs. There were no significant differences between patients who underwent LAAC and patients on DOACs in terms of baseline age (75.0 vs 74.7, p = 0.27), CHA2DS2-VASc score (5.1 vs 5.1, p = 0.33), or HAS-BLED score (3.3 vs 3.3, p = 0.36). After a mean weighted follow-up of 22.0 months, LAAC was associated with significantly lower rates of combined major adverse CV event outcomes (HR 0.73 [0.56 to 0.95], p = 0.02), all-cause mortality (HR 0.68 [0.54 to 0.86], p = 0.02), and CV mortality (HR 0.55 [0.41 to 0.72], p<0.01). There were no significant differences in the rates of ischemic stroke or systemic embolism (HR 1.12 [0.92 to 1.35], p = 0.25), major bleeding (HR 0.94 [0.67 to 1.32], p = 0.71), or hemorrhagic stroke (HR 1.07 [0.74 to 1.54], p = 0.74) between LAAC and DOAC. In conclusion, percutaneous LAAC was found to be as efficacious as DOACs for stroke prevention, with lower all-cause and CV mortality. The rates of major bleeding and hemorrhagic stroke were similar. LAAC has a potential role to play in stroke prevention in patients with atrial fibrillation in the era of DOACs, but further randomized data are needed. |
| first_indexed | 2024-10-01T07:46:03Z |
| format | Journal Article |
| id | ntu-10356/169956 |
| institution | Nanyang Technological University |
| language | English |
| last_indexed | 2024-10-01T07:46:03Z |
| publishDate | 2023 |
| record_format | dspace |
| spelling | ntu-10356/1699562023-08-16T02:37:21Z An updated meta-analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation Jiang, Haowen Koh, Tian Hai Vengkat, Vijay Fei, Gao Ding, Zee Pin Ewe, See Hooi Jappar, Ignasius Lim, Soo Teik Yap, Jonathan Lee Kong Chian School of Medicine (LKCMedicine) National Heart Center, Singapore Science::Medicine Anticoagulation Atrial Fibrillation The availability of direct oral anticoagulants (DOACs) with known lower bleeding risk compared with warfarin have raised questions about the role of left atrial appendage closure (LAAC). We aimed to perform a meta-analysis to compare the clinical outcomes for LAAC versus DOACs. All studies directly comparing LAAC with DOACs up to January 2023 were included. The outcomes studied included the combined major adverse cardiovascular (CV) events outcomes, ischemic stroke and thromboembolic events, major bleeding, CV mortality, and all-cause mortality. Hazard ratios (HRs) and their 95% confidence interval were extracted or estimated from the data and pooled together with a random-effects model. A total of 7 studies (1 randomized controlled trial, 6 propensity-matched observational studies) were finally included, with a pooled population of 4,383 patients who underwent LAAC and 4,554 patients on DOACs. There were no significant differences between patients who underwent LAAC and patients on DOACs in terms of baseline age (75.0 vs 74.7, p = 0.27), CHA2DS2-VASc score (5.1 vs 5.1, p = 0.33), or HAS-BLED score (3.3 vs 3.3, p = 0.36). After a mean weighted follow-up of 22.0 months, LAAC was associated with significantly lower rates of combined major adverse CV event outcomes (HR 0.73 [0.56 to 0.95], p = 0.02), all-cause mortality (HR 0.68 [0.54 to 0.86], p = 0.02), and CV mortality (HR 0.55 [0.41 to 0.72], p<0.01). There were no significant differences in the rates of ischemic stroke or systemic embolism (HR 1.12 [0.92 to 1.35], p = 0.25), major bleeding (HR 0.94 [0.67 to 1.32], p = 0.71), or hemorrhagic stroke (HR 1.07 [0.74 to 1.54], p = 0.74) between LAAC and DOAC. In conclusion, percutaneous LAAC was found to be as efficacious as DOACs for stroke prevention, with lower all-cause and CV mortality. The rates of major bleeding and hemorrhagic stroke were similar. LAAC has a potential role to play in stroke prevention in patients with atrial fibrillation in the era of DOACs, but further randomized data are needed. 2023-08-16T02:37:21Z 2023-08-16T02:37:21Z 2023 Journal Article Jiang, H., Koh, T. H., Vengkat, V., Fei, G., Ding, Z. P., Ewe, S. H., Jappar, I., Lim, S. T. & Yap, J. (2023). An updated meta-analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation. The American Journal of Cardiology, 200, 135-143. https://dx.doi.org/10.1016/j.amjcard.2023.05.044 0002-9149 https://hdl.handle.net/10356/169956 10.1016/j.amjcard.2023.05.044 37321026 2-s2.0-85161965882 200 135 143 en The American Journal of Cardiology © 2023 Elsevier Inc. All rights reserved. |
| spellingShingle | Science::Medicine Anticoagulation Atrial Fibrillation Jiang, Haowen Koh, Tian Hai Vengkat, Vijay Fei, Gao Ding, Zee Pin Ewe, See Hooi Jappar, Ignasius Lim, Soo Teik Yap, Jonathan An updated meta-analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation |
| title | An updated meta-analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation |
| title_full | An updated meta-analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation |
| title_fullStr | An updated meta-analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation |
| title_full_unstemmed | An updated meta-analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation |
| title_short | An updated meta-analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation |
| title_sort | updated meta analysis on the clinical outcomes of percutaneous left atrial appendage closure versus direct oral anticoagulation in patients with atrial fibrillation |
| topic | Science::Medicine Anticoagulation Atrial Fibrillation |
| url | https://hdl.handle.net/10356/169956 |
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