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. 2023 Oct 31;82(18):1765-1773.
doi: 10.1016/j.jacc.2023.08.010. Epub 2023 Aug 21.

Network Meta-Analysis of Initial Antithrombotic Regimens After Left Atrial Appendage Occlusion

Pedro E P Carvalho  1 , Douglas M Gewehr  2 , Isabele A Miyawaki  3 , Alleh Nogueira  4 , Nicole Felix  5 , Philippe Garot  6 , Arthur Darmon  7 , Patrizio Mazzone  8 , Alberto Preda  8 , Bruno R Nascimento  9 , Luiz F Kubrusly  2 , Rhanderson Cardoso  10
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Free article

Network Meta-Analysis of Initial Antithrombotic Regimens After Left Atrial Appendage Occlusion

Pedro E P Carvalho et al. J Am Coll Cardiol. .
Free article

Abstract

Background: The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) in patients with nonvalvular atrial fibrillation (AF) remains uncertain.

Objectives: In this study, the authors sought to compare the efficacy and safety of various antithrombotic strategies after LAAO.

Methods: We searched the Medline, Cochrane, EMBASE, LILACS, and ClinicalTrials.gov databases for studies reporting outcomes after LAAO, stratified by antithrombotic therapy prescribed at postprocedural discharge. Direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), DOAC plus SAPT, VKA plus SAPT, and no antithrombotic therapy were analyzed. We performed a frequentist random effects model network meta-analysis to estimate the OR and 95% CI for each comparison. P-scores provided a ranking of treatments.

Results: Forty-one studies comprising 12,451 patients with nonvalvular AF were included. DAPT, DOAC, DOAC plus SAPT, and VKA were significantly superior to no therapy to prevent device-related thrombosis. DOAC was associated with lower all-cause mortality than VKA (OR: 0.39; 95% CI: 0.17-0.89; P = 0.03). Compared with SAPT, DAPT was associated with fewer thromboembolic events (OR: 0.50; 95% CI: 0.29-0.88; P = 0.02), without a difference in major bleeding. In the analysis of P-scores, DOAC monotherapy was the strategy most likely to have lower thromboembolic events and major bleeding.

Conclusions: In this network meta-analysis comparing initial antithrombotic therapies after LAAO, monotherapy with DOAC had the highest likelihood of lower thromboembolic events and major bleeding. DAPT was associated with a lower incidence of thromboembolic events compared with SAPT and may be a preferred option in patients unable to tolerate anticoagulation.

Keywords: anticoagulants; antiplatelets; antithrombotic therapy; atrial fibrillation; left atrial appendage occlusion.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Darmon has served as a consultant for Boston Scientific and Bayer; and has received research grants from Abbott and Alvimedica. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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