Randomized trials have shown that direct oral anticoagulants (DOACs) are superior
to warfarin in patients with nonvalvular atrial fibrillation. However, long-term use
of anticoagulation carries an inherent risk of bleeding and nonadherence. Although
the use of percutaneous left atrial appendage occlusion (LAAO) has become readily
available, its effectiveness relative to oral anticoagulants is still unclear. The
present study aimed to compare the outcomes of warfarin, DOACs, and LAAO in patients
with atrial fibrillation. Medline, Embase, CENTRAL, and Web of Science were systematically
searched through December 2021 for randomized controlled trials comparing warfarin,
DOACs, or LAAO, reporting on all-cause mortality, stroke, and clinically relevant
bleeding. A random-effects model was used to assess the safety and efficacy outcomes
of these 3 treatments relative to each other in a Bayesian network meta-analysis.
A total of 40 trials with 95,469 patients (LAAO: 5 trials, 3,032 patients; DOAC: 36
trials, 54,327 patients; warfarin: 37 trials, 38,110 patients) were included. LAAO
was associated with significantly lower mortality than warfarin (odds ratio [OR] 0.68;
95% credible interval [CrI] 0.50 to 0.90) and DOACs (OR 0.75, 95% CrI 0.55 to 0.99).
LAAO was the best-ranked treatment with respect to mortality reduction (surface under
the cumulative ranking curve [SUCRA] 98.77%) and bleeding avoidance (SUCRA 72.26%).
Compared with warfarin, DOACs significantly reduced mortality (OR 0.91, 95% CrI 0.85
to 0.97), stroke (OR 0.80, 95% CrI 0.63 to 0.93), and bleeding (OR 0.78, 95% CrI 0.63
to 0.95) and were ranked as the best option at preventing stroke (SUCRA 82.63%). In
conclusion, LAAO was associated with lower mortality compared with DOACs, and both
LAAO and DOACs significantly reduce mortality compared with warfarin. Future trials
are needed to rule out a significant inferiority of LAAO compared with DOACs in terms
of stroke and bleeding risks.
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Article info
Publication history
Published online: October 29, 2022
Received in revised form:
July 19,
2022
Received:
April 29,
2022
Footnotes
Drs. Abdelfattah and Sayed contributed equally as first cojoined authors.
Funding: None.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
