Clinical outcomes of left atrial appendage occlusion versus direct oral anticoagulation in patients with atrial fibrillation and prior ischemic stroke: A propensity-score matched study

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  • Kasper Korsholm
  • Jan Brink Valentin, Aalborg University
  • ,
  • Dorte Damgaard
  • ,
  • Hans-Christoph Diener, University of Duisburg-Essen
  • ,
  • Alan John Camm, St. George's University of London
  • ,
  • Ulf Landmesser, Charité – Universitätsmedizin Berlin
  • ,
  • David Hildick-Smith, Brighton and Sussex University Hospitals NHS Trust
  • ,
  • Søren Paaske Johnsen, Aalborg University
  • ,
  • Jens Erik Nielsen-Kudsk

BACKGROUND: This propensity-score matched study investigated clinical outcomes associated with left atrial appendage occlusion (LAAO) versus direct oral anticoagulation (DOAC) in patients with AF and prior ischemic stroke.

METHODS: AF patients enrolled in the Amulet Observational Study with a history of ischemic stroke and successful LAAO (n = 299) were compared with a propensity-score matched cohort of incident AF patients with prior ischemic stroke and treated by DOAC (n = 301). The control cohort was identified through the Danish National Patient Registries. Propensity score matching was based on covariates of the CHA2DS2-VASc and HAS-BLED scores, with a 1:2 ratio and using Greedy 5:1 digit matching with replacement. The analysis included 2-years follow-up, with a primary composite outcome of ischemic stroke, major bleeding (BARC ≥ 3) or all-cause mortality.

RESULTS: Mean (SD) CHA2DS2-VASc scores were 5.26 (1.42) and 5.40 (1.31) and HAS-BLED scores were 3.95 (0.91) and 4.03 (0.96), for the LAAO and DOAC group, respectively. Total number of primary composite outcome events were 61 (12.4 events/100 patient-years) and 117 (26.9 events/100 patient-years) in the LAAO and DOAC group, respectively. Risk of the primary composite outcome was significantly lower in the LAAO group, hazard rate ratio [HR] 0.48 (95% CI: 0.35-0.65). Ischemic stroke risk was comparable, HR 0.71 (95% CI: 0.34-1.45), while risk of major bleeding, HR 0.41 (95% CI: 0.25-0.67), and all-cause mortality, HR 0.48 (95% CI: 0.32-0.71), were significantly lower with LAAO. Cardiovascular mortality did not differ statistically between the LAAO and DOAC group, HR 0.75 (95% CI: 0.39-1.42). Results were consistent across sensitivity analyses.

CONCLUSION: This study indicated significantly lower risk of the composite outcome of stroke, major bleeding and all-cause mortality with LAAO therapy compared to DOAC, in patients with AF and prior stroke. The stroke prevention effectiveness appeared similar, with a significantly lower risk of major bleeding events with LAAO. The suggested clinical benefit of LAAO over DOAC require confirmation in the ongoing randomized OCCLUSION-AF trial.

Original languageEnglish
JournalInternational Journal of Cardiology
Volume363
Pages (from-to)56-63
Number of pages8
ISSN0167-5273
DOIs
Publication statusPublished - 15 Sep 2022

Bibliographical note

Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.

    Research areas

  • Anticoagulants, Atrial Appendage/surgery, Atrial Fibrillation/complications, Hemorrhage/chemically induced, Humans, Ischemic Stroke, Propensity Score, Stroke/diagnosis, Treatment Outcome

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