Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation : A Decision Analysis.

Simple item page
dc.contributor.author

Chew, Derek S

dc.contributor.author

Zhou, Ke

dc.contributor.author

Pokorney, Sean D

dc.contributor.author

Matchar, David B

dc.contributor.author

Vemulapalli, Sreekanth

dc.contributor.author

Allen, Larry A

dc.contributor.author

Jackson, Kevin P

dc.contributor.author

Samad, Zainab

dc.contributor.author

Patel, Manesh R

dc.contributor.author

Freeman, James V

dc.contributor.author

Piccini, Jonathan P

dc.date.accessioned

2022-10-03T00:40:27Z

dc.date.available

2022-10-03T00:40:27Z

dc.date.issued

2022-08

dc.date.updated

2022-10-03T00:40:26Z

dc.description.abstract

Background

Left atrial appendage occlusion (LAAO) is a potential alternative to oral anticoagulants in selected patients with atrial fibrillation (AF). Compared with anticoagulants, LAAO decreases major bleeding risk, but there is uncertainty regarding the risk for ischemic stroke compared with anticoagulation.

Objective

To determine the optimal strategy for stroke prevention conditional on a patient's individual risks for ischemic stroke and bleeding.

Design

Decision analysis with a Markov model.

Data sources

Evidence from the published literature informed model inputs.

Target population

Women and men with nonvalvular AF and without prior stroke.

Time horizon

Lifetime.

Perspective

Clinical.

Intervention

LAAO versus warfarin or direct oral anticoagulants (DOACs).

Outcome measures

The primary end point was clinical benefit measured in quality-adjusted life-years.

Results of base-case analysis

The baseline risks for stroke and bleeding determined whether LAAO was preferred over anticoagulants in patients with AF. The combined risks favored LAAO for higher bleeding risk, but that benefit became less certain at higher stroke risks. For example, at a HAS-BLED score of 5, LAAO was favored in more than 80% of model simulations for CHA2DS2-VASc scores between 2 and 5. The probability of LAAO benefit in QALYs (>80%) at lower bleeding risks (HAS-BLED score of 0 to 1) was limited to patients with lower stroke risks (CHA2DS2-VASc score of 2). Because DOACs carry lower bleeding risks than warfarin, the net benefit of LAAO is less certain than that of DOACs.

Results of sensitivity analysis

Results were consistent using the ORBIT bleeding score instead of the HAS-BLED score, as well as alternative sources for LAAO clinical effectiveness data.

Limitation

Clinical effectiveness data were drawn primarily from studies on the Watchman device.

Conclusion

Although LAAO could be an alternative to anticoagulants for stroke prevention in patients with AF and high bleeding risk, the overall benefit from LAAO depends on the combination of stroke and bleeding risks in individual patients. These results suggest the need for a sufficiently low stroke risk for LAAO to be beneficial. The authors believe that these results could improve shared decision making when selecting patients for LAAO.

Primary funding source

None.
dc.identifier.issn

0003-4819

dc.identifier.issn

1539-3704

dc.identifier.uri

https://hdl.handle.net/10161/26014

dc.language

eng

dc.publisher

American College of Physicians

dc.relation.ispartof

Annals of internal medicine

dc.relation.isversionof

10.7326/m21-4653

dc.title

Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation : A Decision Analysis.

dc.type

Journal article

duke.contributor.orcid

Pokorney, Sean D|0000-0002-4345-0816

duke.contributor.orcid

Matchar, David B|0000-0003-3020-2108

duke.contributor.orcid

Vemulapalli, Sreekanth|0000-0003-1599-2957

duke.contributor.orcid

Patel, Manesh R|0000-0001-6477-9728

duke.contributor.orcid

Piccini, Jonathan P|0000-0003-0772-2404

pubs.begin-page

1230

pubs.end-page

1239

pubs.issue

9

pubs.organisational-group

Duke

pubs.organisational-group

School of Medicine

pubs.organisational-group

Clinical Science Departments

pubs.organisational-group

Medicine

pubs.organisational-group

Pathology

pubs.organisational-group

Medicine, General Internal Medicine

pubs.organisational-group

Institutes and Provost's Academic Units

pubs.organisational-group

University Institutes and Centers

pubs.organisational-group

Duke Global Health Institute

pubs.publication-status

Published

pubs.volume

175

Files

Original bundle

Now showing 1 - 1 of 1
Thumbnail Image
Name:
Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation - A Decision Analysis.pdf
Size:
226.82 KB
Format:
Adobe Portable Document Format
Download

Collections

Scholarly Articles