Less stroke severity, mortality after LAA closure vs. DOAC prophylaxis
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Key takeaways:
- Patients with atrial fibrillation experienced fewer disabling or fatal strokes with left atrial appendage closure vs. direct oral anticoagulants.
- Data suggest a lower thromboembolic burden after LAA closure.
In adults with atrial fibrillation who developed ischemic stroke, those treated with left atrial appendage closure had better outcomes than those receiving direct oral anticoagulant prophylaxis, data from a registry analysis show.
“There is a fair amount of data that with appendage closure vs. [warfarin], and even for appendage closure vs. new oral anticoagulants, that there is less stroke mortality, and we do not really understand why,” Vivek Y. Reddy, MD, director of cardiac arrhythmia services at Mount Sinai Hospital and the Mount Sinai Health System, told Healio. “The number of hemorrhagic strokes are just too small to account for the mortality difference observed. In looking at stroke severity, what we saw in our analysis is that strokes that occur in the context of appendage closure tend to be smaller and are less likely to be disabling or fatal than in the context of new oral anticoagulants.”
In a retrospective study published in JACC: Clinical Electrophysiology, Reddy and colleagues analyzed data from 322 patients undergoing left atrial appendage closure (LAAC) at eight centers who developed an ischemic stroke compared with 125 contemporaneous consecutive patients who developed ischemic stroke during treatment with direct oral anticoagulants (DOACs). The mean patient age was 74 years and 55% were men. In the LAAC group, 89% of patients received a Watchman device (Boston Scientific); 9% received a Watchman-FLX device (Boston Scientific) and 2% received an Amulet device (Abbott). In the DOAC cohort, 55% of patients received apixaban (Eliquis, Bristol Myers Squibb/Pfizer), 29% received rivaroxaban (Xarelto, Janssen/Bayer) and 16% received dabigatran (Pradaxa, Boehringer Ingelheim). The primary outcome was disabling/fatal stroke (modified Rankin Scale score 3 to 5) at discharge and 3 months later.
Researchers found that, despite higher baseline comorbidities, patients in the LAAC group experienced less severe ischemic strokes than the DOAC group at discharge and 3 months.
The incidence of disabling or fatal ischemic stroke at discharge (38.3% vs. 70.3%; P < .001) and at 3 months (33.3% vs. 56.2%; P < 0.001) were lower with LAAC compared with DOAC. There was no difference in mortality between groups during hospitalization; however, mortality 3 months after stroke (14.7% vs. 32.1%; P = .002) was lower in the LAAC group.
LAAC was independently associated with fewer disabling or fatal strokes at discharge (OR = 0.22; 95% CI, 0.13-0.39; P < .001) and 3 months (OR = 0.25; 95% CI, 0.12-0.5; P < .001), and fewer deaths at 3 months (OR = 0.28; 95% CI, 0.12-0.64; P = .002).
“When we did the propensity match analyses, we saw that the difference was even more profound,” Reddy said during an interview. “Disabling and fatal stroke was even more in favor of appendage closure. We feel pretty good about the quality of these data, but you always worry there are confounders we are not considering. We did many analyses to try and account for that and they did not change our conclusions at all.”
Reddy said the data show that “if you have a patient who qualifies for an appendage closure, you should feel good about putting it in. These patients do well and the strokes that do occur are less severe than those in the context of DOACs.”
Researchers continue to study what mechanisms are behind the differences in outcomes. Reddy said one possibility is a lower thromboembolic burden after LAAC than during DOAC therapy; however, vascular and brain imaging data are needed to learn more.
Another potential mechanism is an increase in hemorrhagic transfer after ischemic stroke among patients taking DOACs, Reddy said.
For more information:
Vivek Y. Reddy, MD, can be reached at vivek.reddy@mountsinai.org; X (Twitter): @vivekreddymd.
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