LAAC Does Not Supplant Anticoagulation for Stroke Prevention in AF, Suggests Study
Italy: At long-term follow-up, transcatheter left atrial appendage closure (LAAC) showed similar rates of overall stroke and major bleeding compared with oral anticoagulation (OAC) in patients with atrial fibrillation. However, LAAC was associated with higher ischemic stroke risk but lower nonprocedure-related major bleeding. Overall, these findings do not support routine use of LAAC as a first-line alternative to OAC for stroke prevention in AF patients at moderate-to-high stroke risk.
The findings come from a systematic review and meta-analysis published in JAMA Cardiology, led by Claudio Laudani, Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico Rodolico–San Marco, University of Catania, Catania, Italy, and colleagues. The researchers evaluated whether catheter-based LAAC could provide comparable efficacy and safety to OAC in patients with AF who are at elevated risk of stroke.
OAC remains the standard approach for preventing thromboembolic stroke in AF, although its use is accompanied by an increased risk of bleeding. LAAC has emerged as a procedural alternative that excludes the left atrial appendage, a major source of thrombus formation in AF. However, uncertainty has remained regarding whether its long-term benefits outweigh those of anticoagulation.
For the analysis, researchers searched PubMed, Cochrane Central, and Web of Science through March 2026, along with cardiology society websites, news sources, and reference lists. Eight randomized clinical trials involving 7,434 patients were included. Participants had been randomly assigned to catheter-based LAAC or OAC, with outcomes pooled using a random-effects model.
Key Findings:
- At a weighted mean follow-up of 37.9 months, LAAC and OAC showed no significant difference in overall stroke rates (IRR, 1.08).
- Major bleeding rates were also similar between LAAC and OAC (IRR, 0.96).
- LAAC was associated with a 34% higher risk of ischemic stroke compared with OAC (IRR, 1.34).
- In contrast, LAAC was linked to a 27% lower risk of nonprocedural major bleeding (IRR, 0.73).
- Among every 1,000 patients undergoing LAAC, approximately 5 experienced periprocedural stroke, 9 had bleeding, 1 died, 5 experienced device embolization, and 9 developed pericardial effusion.
The investigators emphasized that these results highlight a trade-off between ischemic and bleeding outcomes rather than a clear overall advantage of LAAC over anticoagulation. Although the procedure may reduce bleeding unrelated to the intervention, this benefit is accompanied by a greater risk of ischemic stroke.
The authors concluded that LAAC should not routinely replace OAC as the first-line stroke-prevention strategy in AF patients at moderate-to-high stroke risk. The findings may nevertheless help inform individualized treatment decisions, particularly when weighing a patient's risks of ischemic stroke against bleeding.
Reference:
Laudani C, Bujak K, Giacoppo D, et al. Catheter-Based Left Atrial Appendage Closure vs Oral Anticoagulation in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. JAMA Cardiol. Published online August 26, 2026. doi:10.1001/jamacardio.2026.2640
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