Cardiovasc Prev Pharmacother.  2022 Jan;4(1):18-25. 10.36011/cpp.2022.4.e1.

Indirect comparison of nonvitamin K oral anticoagulants and left atrial appendage occlusion

• Kim SH
• Park SY
• Hwang SS

• KMID: 2536929
• DOI: http://doi.org/10.36011/cpp.2022.4.e1

Abstract

Background
Anticoagulation is important in atrial fibrillation (AF) patients to reduce the occurrence of thrombotic events. We evaluated the efficacy and safety of percutaneous left atrial appendage occlusion (LAAO) as an alternative to systemic anticoagulation through an indirect comparative analysis.
Methods
An indirect comparative analysis of nonvitamin K oral anticoagulants (NOACs) and LAAO was conducted. Comparisons were made using data from four landmark randomized clinical trials (RE-LY, ROCKET-AF, ARISTOTLE, and PROTECT AF). Using warfarin as the common comparator, an indirect comparison was performed using data from each trial, and the relative risk was calculated between NOACs and LAAO.
Results
NOACs and LAAO showed similar results for the reduction of stroke and systemic embolism, with a non-statistically significant trend favoring NOACs (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.37–1.46 for dabigatran; HR, 0.99; 95% CI, 0.50–1.92 for rivaroxaban; HR, 0.89; 95% CI, 0.45–1.74 for apixaban). Significantly fewer major bleeding and procedure-related complications were found in patients treated with apixaban compared with LAAO (HR, 0.45; 95% CI, 0.26–0.75). Cardiovascular death occurred more frequently in patients administered NOACs than in patients with LAAO (HR, 2.28; 95% CI, 1.03–5.10 for dabigatran; HR, 2.41; 95% CI, 1.09–5.42 for rivaroxaban; HR, 2.40; 95% CI, 1.10–5.36 for apixaban).
Conclusions
The rate of all-cause death was similar between NOACs and LAAO. Compared with LAAO, NOACs led to a nonsignificant numerical decrease in stroke and embolism in AF patients. Significantly fewer safety events occurred in patients treated with apixaban. LAAO significantly reduced cardiovascular death.

Keyword

Atrial fibrillation; Stroke; Anticoagulants; Atrial appendage

Figure

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  Fig. 1. Evidence network of the four reported randomized controlled trials of new oral anticoagulant and left atrial appendage occlusion in patients with nonvalvular atrial fibrillation at risk of stroke. The dashed lines represent indirect comparisons from the present study.

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  Fig. 2. New oral anticoagulants (NOACs) versus left atrial appendage occlusion (LAAO). The plot shows the hazard ratios (HRs) and 95% confidence intervals (CIs) for each outcome with NOACs versus LAAO estimated from the indirect comparisons.

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