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Anticoagulation Alone vs. Anticoagulation Plus Aspirin or DAPT After LAAO
Quick Takes
- Among patients receiving the second-generation LAA closure device, the lowest rate of adverse events occurred in patients receiving DOAC alone at discharge, driven by lower rates of major bleeding without an increase in thrombotic events.
- Of note, warfarin alone also showed a lower rate of major bleeding compared with DOAC plus aspirin.
- These data suggest that following LAAO implantation, avoiding addition of aspirin represents an opportunity to improve patient outcomes, primarily through a reduced risk of major bleeding without an increased risk of thromboembolic events.
Study Questions:
What are the patterns of antithrombotic medication strategies at discharge following left atrial appendage occlusion (LAAO) with the Watchman FLX device in real-world practice, and the risk of adverse events among the different antithrombotic regimens?
Methods:
The investigators evaluated patients in the NCDR (National Cardiovascular Data Registry) LAAO Registry who underwent LAAO with the second-generation LAA closure device between 2020 and 2022. They grouped patients by mutually exclusive discharge antithrombotic strategies and compared the rates of adverse events at 45 days and 6 months using multivariable Cox proportional hazards regression.
Results:
Among 53,878 patients undergoing successful LAAO with the second-generation LAA closure device, the most common antithrombotic discharge regimens were direct oral anticoagulant (DOAC) plus aspirin (48.3%), DOAC alone (22.6%), dual antiplatelet therapy (8.1%), warfarin plus aspirin (7.7%), and DOAC plus P2Y12 inhibitor (4.9%). In multivariate analysis, DOAC alone had a lower rate of major adverse events and major bleeding at 45 days of follow-up compared with DOAC plus aspirin (major adverse events: hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.68-0.91; major bleeding: HR, 0.69; 95% CI, 0.60-0.80). These differences persisted at 6 months. Warfarin without aspirin also showed lower rates of major bleeding at both time points. No differences were seen in stroke/transient ischemic attack or device-related thrombus.
Conclusions:
The authors report that discharge on DOAC alone or warfarin alone following LAAO was associated with a lower rate of adverse events compared with DOAC plus aspirin.
Perspective:
This study reports that among patients receiving the second-generation LAA closure device, the lowest rate of major adverse events occurred in patients receiving DOAC alone at discharge, driven by lower rates of major bleeding without an increase in thrombotic events. Of note, warfarin alone also showed a lower rate of major bleeding compared with DOAC plus aspirin. These data suggest that following LAAO implantation, avoiding addition of aspirin represents a substantial opportunity to improve patient outcomes, primarily through a reduced risk of major bleeding without an increased risk of thromboembolic events. Given availability of newer devices, additional studies are indicated to define the optimal regimen and duration of postprocedure antithrombotic therapy tailored to the patient, device, and procedural characteristics for patients with atrial fibrillation undergoing LAAO.
Clinical Topics: Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention, Prevention
Keywords: Anticoagulants, Atrial Appendage, LAAO Registry, Platelet Aggregation Inhibitors, Thromboembolism
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