The following is the summary of “Meta-Analysis Comparing Left Atrial Appendage Occlusion, Direct Oral Anticoagulants, and Warfarin for Nonvalvular Atrial Fibrillation,” published in the January 2023 issue of Cardiovascular Disease by Abdelfattah et al.

In randomized clinical trials, direct oral anticoagulants (DOACs) have been more effective than warfarin in patients with nonvalvular atrial fibrillation. However, bleeding and nonadherence are risks associated with anticoagulant treatment over the long run. Although left atrial appendage occlusion (LAAO) may now be performed with reasonable ease, the evidence for its efficacy compared to oral anticoagulants is mixed. Results of warfarin, DOACs, and LAAO for atrial fibrillation patients were compared in this study. Randomized controlled trials comparing warfarin, DOACs, or LAAO that report on all-cause mortality, stroke, and clinically significant bleeding were sought by a systematic search of Medline, Embase, CENTRAL, and Web of Science through December 2021. In a Bayesian network meta-analysis, the three therapies were compared regarding their safety and efficacy using a random-effects model. 

There were 40 studies with 95,469 patients (5 with 3,032 patients for LAAO, 36 with 54,327 patients for DOAC, and 37 with 38,110 for warfarin). Death rates were shown to be considerably reduced with LAAO compared to both warfarin and direct-acting oral anticoagulants (DOACs) (odds ratio [OR] 0.68; 95% credible interval [CrI] 0.50 to 0.90). Both in terms of reducing mortality (surface under the cumulative ranking curve [SUCRA]=98.77%) and preventing bleeding (SUCRA=72.26), LAAO ranked as the highest possible treatment. 

DOACs were ranked as the best option in preventing stroke (SUCRA 82.63%), and they significantly reduced death (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). To sum up, LAAO was related to less death than DOACs, and both LAAO and DOACs considerably cut death over warfarin. To disprove LAAO’s potential sub-parity to DOACs concerning stroke and bleeding risks, more research is needed.

Source: https://www.sciencedirect.com/science/article/abs/pii/S000291492200844X