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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References
- 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol. 2019; 74: 104-132
- PROTECT AF Steering Committee and Investigators. Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial.JAMA. 2014; 312: 1988-1998
- EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion – an update.EuroIntervention. 2020; 15: 1133-1180
- PRAGUE-17 Trial Investigators. 4-year outcomes After left atrial appendage closure Versus nonwarfarin oral anticoagulation for atrial fibrillation.J Am Coll Cardiol. 2022; 79: 1-14
- Prospective randomized evaluation of the Watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: The PREVAIL trial.J Am Coll Cardiol. 2014; 64: 1-12
- The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.Ann Intern Med. 2015; 162: 777-784
- Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial.J Clin Epidemiol. 2011; 64: 163-171
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.2; 2021. Cochrane. Available at: http://www.training.cochrane.org/handbook. Accessed on March 15, 2021.
- R: A Language and Environment for Statistical Computing.R Foundation for Statistical Computing, 2021 (Accessed on June 25, 2021)
- Inference from iterative simulation using multiple sequences.Stat Sci. 1992; 7: 457-472
- RoB 2: a revised tool for assessing risk of bias in randomised trials.BMJ. 2019; 366: l4898
- Edoxaban versus vitamin K Antagonist for atrial fibrillation after TAVR.N Engl J Med. 2021; 385: 2150-2160
- AREST Investigators Early apixaban use following stroke in patients with atrial fibrillation: results of the AREST trial.Stroke. 2021; 52: 1164-1171
- Amplatzer Amulet left atrial appendage occluder versus watchman device for stroke prophylaxis (Amulet IDE): a randomized, controlled trial.Circulation. 2021; 144: 1543-1552
- MO123USE of rivaroxaban versus warfarin in patients with atrial fibrillation and advanced chronic kidney disease*.Nephrol Dial Transplant. 2021; 36
- Safety and Efficacy of vitamin K antagonists versus rivaroxaban in hemodialysis patients with atrial fibrillation: a multicenter randomized controlled trial.J Am Soc Nephrol. 2021; 32: 1474-1483
- Amulet or Watchman device for percutaneous left atrial appendage closure: primary results of the SWISS-APERO randomized clinical trial.Circulation. 2022; 145: 724-738
ClinicalTrials.gov. A dose response study of dabigatran etexilate (BIBR 1048) in pharmacodynamics and safety in patients with non-valvular atrial fibrillation in comparison to warfarin. Available at:https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjQn62A8db5AhVA1jgGHX5rCnkQFnoECAIQAQ&url=https%3A%2F%2Fclinicaltrials.gov%2Fct2%2Fshow%2FNCT01136408&usg=AOvVaw0UKzJbk0ybWg5EUzyQI8cl. Accessed on June 10, 2021.
- PREVAIL and PROTECT AF Investigators. 5-year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF trials.J Am Coll Cardiol. 2017; 70: 2964-2975
- National trends in patients hospitalized for stroke and stroke mortality in France, 2008 to 2014.Stroke. 2017; 48: 2939-2945
- Bleeding outcomes after left atrial appendage closure compared with long-term warfarin: a pooled, patient-level analysis of the WATCHMAN randomized trial experience.JACC Cardiovasc Interv. 2015; 8: 1925-1932
- Left atrial appendage closure Versus oral anticoagulants in atrial fibrillation: a meta-analysis of randomized trials.J Am Coll Cardiol. 2020; 76: 2795-2797
- Clinical outcomes associated With left atrial appendage occlusion Versus direct oral anticoagulation in atrial fibrillation.JACC Cardiovasc Interv. 2021; 14: 69-78
- Over 1-year efficacy and safety of left atrial appendage occlusion versus novel oral anticoagulants for stroke prevention in atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials and observational studies.Heart Rhythm. 2016; 13: 1203-1214
- Comparison of Watchman device with new oral anti-coagulants in patients with atrial fibrillation: a network meta-analysis.Int J Cardiol. 2016; 205: 17-22
- Adherence and persistence to direct oral anticoagulants in atrial fibrillation: a population-based study.Heart. 2020; 106: 119-126
- Real-world adherence and persistence to direct oral anticoagulants in patients with atrial fibrillation: a systematic review and meta-analysis.Circ Cardiovasc Qual Outcomes. 2020; 13e005969
Kapadia SR. SurPASS analysis, national cardiovascular data registry (NCDR) left atrial appendage occlusion (LAAO) registry-late-breaking trial session at the cardiovascular research technologies (CRT). Available at: https://www.watchman.com/en-us-implanter/clinical-evidence/surpass.html. Accessed on April 26, 2022.
- Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis.BMJ. 2017; 359: j5058
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.
