Short-Term Antiplatelet Versus Anticoagulant Therapy After Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis

Abstract

Objectives: The aim of this study was to compare bleeding, thromboembolic, device-related thrombus (DRT), and all-cause mortality events between patients treated with short-term oral anticoagulation (OAC) and those treated with short-term antiplatelet therapy (APT) following left atrial appendage occlusion (LAAO).

Background: Short-term OAC is recommended for patients following LAAO. However, in practice many patients receive APT rather than OAC because of excessive bleeding risk. However, the safety and efficacy of APT compared with OAC have been debated.

Methods: A search was conducted of databases for studies comparing OAC with APT following LAAO. The outcomes of interest were all-cause stroke, major bleeding, DRT, and all-cause mortality. Noncomparative studies were pooled into a single study to generate comparisons of the studies' outcomes. Effects measure were pooled using the random-effect model.

Results: A total of 83 studies with 12,326 patients (APT, n = 7,900; OAC, n = 4,151) were included. Mean CHA₂DS₂-VASc and HAS-BLED scores were 4.1 ± 1.6 and 3.0 ± 1.3, respectively. There were no significance differences between the APT and OAC groups with regard to stroke (risk ratio [RR]: 1.04; 95% confidence interval [CI]: 0.54 to 1.98; p = 0.91; I² = 31%), major bleeding (RR: 1.12; 95% CI: 0.68 to 1.84; p = 0.65; I² = 53%), DRT (RR: 1.33; 95% CI: 0.74 to 2.39; p = 0.33; I² = 36%), and all-cause mortality (RR: 1.29; 95% CI: 0.40 to 4.09; p = 0.18; I² = 36%). These findings persisted in multiple secondary analyses: 1) excluding studies that reported no events; 2) including comparative studies only; 3) excluding patients who were treated with single APT; and 4) removing one study at a time to assess the effect of each study on the overall effect size. There was also no difference in the studies' endpoints among patients who received different LAAO devices.

Conclusions: In a meta-analysis of observational data, there were no differences in the occurrence of stroke, major bleeding DRT, and all-cause mortality in patients treated with short-term OAC or APT following LAAO.

Keywords: antiplatelet therapy; atrial fibrillation; left atrial appendage occlusion; oral anticoagulation; stroke.

FIGURE 1. Forest Plot Comparing APT and OAC

APT = antiplatelet therapy; CI = confidence interval; DRT = device-related thrombus; M-H = Mantel-Haenszel; NE = not estimable; OAC = oral anticoagulation; RR = risk ratio.

FIGURE 2. Forest Plot Comparing APT and OAC After Excluding Studies That Reported Zero Events

Abbreviations as in Figure 1.

FIGURE 3. Forest Plot Comparing APT and OAC After Excluding Single-Arm Studies

Abbreviations as in Figure 1.

FIGURE 4. Forest Plot Comparing Dual APT and OAC

DAPT = dual-antiplatelet therapy; other abbreviations as in Figure 1.

CENTRAL ILLUSTRATION

Study Flowchart