Network Meta-Analysis of Initial Antithrombotic Regimens After Left Atrial Appendage Occlusion

医学 抗血栓 左心耳阻塞 心房颤动 内科学 荟萃分析 纤溶剂 华法林 血栓形成 心脏病学
作者
Pedro E.P. Carvalho,Douglas Mesadri Gewehr,Isabele Ayumi Miyawaki,Allêh Nogueira,Nicole Felix,Philippe Garot,Arthur Darmon,Patrizio Mazzone,Alberto Preda,Bruno Ramos Nascimento,Luiz Fernandao KUBRUSLY,Rhanderson Cardoso
出处
期刊:Journal of the American College of Cardiology [Elsevier BV]
卷期号:82 (18): 1765-1773 被引量:19
标识
DOI:10.1016/j.jacc.2023.08.010
摘要

The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) in patients with nonvalvular atrial fibrillation (AF) remains uncertain. In this study, the authors sought to compare the efficacy and safety of various antithrombotic strategies after LAAO. We searched the Medline, Cochrane, EMBASE, LILACS, and ClinicalTrials.gov databases for studies reporting outcomes after LAAO, stratified by antithrombotic therapy prescribed at postprocedural discharge. Direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), DOAC plus SAPT, VKA plus SAPT, and no antithrombotic therapy were analyzed. We performed a frequentist random effects model network meta-analysis to estimate the OR and 95% CI for each comparison. P-scores provided a ranking of treatments. Forty-one studies comprising 12,451 patients with nonvalvular AF were included. DAPT, DOAC, DOAC plus SAPT, and VKA were significantly superior to no therapy to prevent device-related thrombosis. DOAC was associated with lower all-cause mortality than VKA (OR: 0.39; 95% CI: 0.17-0.89; P = 0.03). Compared with SAPT, DAPT was associated with fewer thromboembolic events (OR: 0.50; 95% CI: 0.29-0.88; P = 0.02), without a difference in major bleeding. In the analysis of P-scores, DOAC monotherapy was the strategy most likely to have lower thromboembolic events and major bleeding. In this network meta-analysis comparing initial antithrombotic therapies after LAAO, monotherapy with DOAC had the highest likelihood of lower thromboembolic events and major bleeding. DAPT was associated with a lower incidence of thromboembolic events compared with SAPT and may be a preferred option in patients unable to tolerate anticoagulation.
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