Author + information
- Luis Nombela Franco1,
- Shweta Sahay2,
- Josep Rodés-Cabau3,
- Pilar Jimenez4,
- Pablo Salinas5,
- Corina Biagioni6,
- Ivan Nuñez-Gil7,
- Nieves Gonzalo8,
- Antonio Fernandez-Ortiz9,
- Javier Escaned10 and
- Carlos Macaya11
- 1Hospital Clínico San Carlos, Madrid, Spain
- 2Royal Adelaide Hospital, ADELAIDE, South Australia, Australia
- 3Quebec Heart and Lung Institute/Laval University, Quebec, Quebec, Canada
- 4Hospital Clinico San Carlos, Madrid, Spain
- 5Hospital Clínico San Carlos, Madrid, Spain
- 6Hospital Clínico San Carlos
- 7Hospital Clínico San Carlos
- 8Hospital Clínico San Carlos, Madrid, Spain
- 9Hospital Clínico San Carlos
- 10Hospital Clínico San Carlos, Madrid, Spain
- 11Hospital Clinico de San Carlos, Madrid, Spain
The effectiveness of vitamin K antagonist (VKA) versus placebo and antiplatelet treatment (APT) is well stablished for stroke prevention in atrial fibrillation (AF). Non-vitamin K antagonist oral anticoagulants (NOAC) are mostly superior to VKA in stroke and intracranial bleeding prevention. Recent randomized controlled trials (RCT) suggested the non-inferiority of percutaneous left atrial appendage closure (LAAC) versus VKA. However, comparisons between LAAC versus placebo, APT or NOAC are lacking. The purpose of this network meta-analysis was to assess the efficacy and safety of LAAC compared to other strategies for stroke prevention in patients with AF.
We pooled together all RCT comparing warfarin to placebo, APT or NOAC in patients with AF using meta-analysis guidelines. Two major trials of LAAC were also included and a network meta-analysis was performed to compare the impact of LAAC on mortality, stroke/systemic embolism (SE) and major bleeding in relation to medical treatment.
The network meta-analysis included 19 RCT with a total of 87,831 patients with AF receiving anticoagulants, APT, placebo or LAAC. Indirect comparison with network meta-analysis using warfarin as the common comparator; revealed statistically significant efficacy benefit favoring LAAC as compared to placebo (mortality: HR 0.38, 95%CI:0.22-0.67, p<0.001; stroke/SE: HR 0.24, 95%CI:0.11-0.52, p<0.001) and APT (mortality: HR 0.58, 95%CI 0.37-0.91, p=0.0018; stroke/SE: HR 0.44, 95%CI:0.23-0.86, p=0.017) and similar to NOAC (mortality: HR 0.76, 95%CI:0.50-1.16, p=0.211; stroke/SE: HR 1.01, 95%CI:0.53-1.92, p=0.969). LAAC showed comparable rates of major bleeding when compared to placebo (HR 2.33, 95%CI:0.67-8.09, p=0.183), APT (HR 0.75, 95%CI:0.30-1.88, p=0.542) and NOAC (HR 0.80, 95%CI:0.33-1.94, p=0.615).
Left atrial appendage closure is superior to placebo and APT and non-inferior to NOAC for preventing mortality and stroke or SE with similar bleeding risk in patients with non-valvular AF.
STRUCTURAL: Left Atrial Appendage Exclusion