Decision model favors left atrial appendage occlusion for stroke prevention in patients at highest risk for bleeding


A decision model found that the relative clinical benefit of left atrial appendage occlusion (LAAO) and oral anticoagulants (OAC) in patients with atrial fibrillation depends on the patients’ baseline risks for stroke and bleeding. LAAOs were found to be the preferred strategy in those with the highest bleeding risk. This benefit became less certain with increasing risk for ischemic stroke and decreasing bleeding risk.

LAAO is a potential alternative to OAC in selected patients with atrial fibrillation. Compared with anticoagulants, LAAO decreases major bleeding risk, but concerns remain over the possible increased risk of ischemic stroke.

Researchers from the Libin Cardiovascular Institute, University of Calgary and the Duke Clinical Research Institute, Duke University used a decision-analytic model to simulate a virtual clinical trial of stroke prevention strategies in a cohort of elderly individuals with AF and without prior stroke to better understand the risk–benefit tradeoffs when choosing between LAAO and OACs contingent on a patient’s stroke risk and bleeding risk.

The primary end point was clinical benefit measured in quality adjusted life-years, and the secondary end points were life expectancy or life-years and net clinical benefit. The researchers found that the clinical benefit of LAAO over OACs depends on the patient-specific baseline risk for stroke and bleeding. Although LAAOs were favorable among patients with the highest bleeding risk, that benefit became less certain at higher stroke risk. According to the researchers, these findings may help to inform shared decision making when selecting patients for LAAO.