In AF, LAA closure may be best suited for patients at low stroke risk, high bleeding risk
Click Here to Manage Email Alerts
In a decision analysis comparing left atrial appendage occlusion and oral anticoagulation in atrial fibrillation, left atrial appendage occlusion tended to be favored when patients were at low risk for stroke and high risk for bleeding.
Derek S. Chew, MD, MSc, cardiac electrophysiologist at Libin Cardiovascular Institute, University of Calgary, Alberta, Canada, and colleagues conducted a decision analysis with a Markov model to determine a patient’s optimal stroke prevention strategy depending on stroke and bleeding risk.
“Left atrial appendage occlusion (LAAO) is a potential alternative to oral anticoagulants in selected patients with AF,” Chew and colleagues wrote. “Compared with anticoagulants, LAAO decreases major bleeding risk, but there is uncertainty regarding the risk of ischemic stroke compared with anticoagulation.”
The primary endpoint was clinical benefit as measured by quality-adjusted life-years.
In the base-case analysis, the optimal strategy was influenced by baseline risks for stroke and bleeding, the researchers wrote.
“The combined risks favored LAAO for higher bleeding risk, but that benefit became less certain at higher stroke risks,” they wrote. “For example, at a HAS-BLED score of 5, LAAO was favored in more than 80% of model simulations for CHA2DS2-VASc scores between 2 and 5.”
In patients at low bleeding risk, with HAS-BLED scores of 0 or 1, the probability that LAAO would yield more QALYs than oral anticoagulation in at least 80% of model simulations was limited only to patients at low stroke risk, with a CHA2DS2-VASc score of 2 or lower, according to the researchers.
Because direct oral anticoagulants are associated with less bleeding than warfarin, their net benefit is more certain than that of LAAO, Chew and colleagues wrote.
In sensitivity analyses, the results did not change when the ORBIT score was used instead of the HAS-BLED score, nor did they change when different sources for LAAO clinical effectiveness data were used.
“The relative clinical benefit of LAAO and oral anticoagulants in patients with AF depends on the patients’ baseline risks for stroke and bleeding,” Chew and colleagues wrote. “The LAAO strategy was preferred in those with the highest risk for bleeding. However, the benefit became less certain with increasing risk for ischemic stroke and decreasing bleeding risk. This description of LAAO benefit has the potential to improve shared decision-making when selecting patients for LAAO.”
In a related editorial, Bharat K. Kantharia, MD, clinical professor of medicine at Icahn School of Medicine at Mount Sinai and president of Cardiovascular and Heart Rhythm Consultants in New York, wrote: “Chen and colleagues’ innovative and insightful work has substantial scientific merit. However, clinicians caring for patients with AF need further research to guide decisions when faced with the dilemma of anticoagulation vs. LAAO.”
Reference:
Collapse
Read more about
Click Here to Manage Email Alerts