Left Atrial Appendage Closure vs Anticoagulation for Stroke Prevention in Atrial Fibrillation: Meta-Analysis of Randomized Trials

Why clinicians should know about it

• Picked for Epidemiology (paper of the day, 26 July 2026): Meta‑analysis of randomized trials comparing LAAC vs anticoagulation
• Picked for Physiology (medical) (paper of the day, 26 July 2026).
• Picked for Cardiology and Cardiovascular Medicine (top studies of the week, 26 July 2026): Meta-analysis of LAAC vs OAC RCTs
• Picked for Hematology (top studies of the week, 26 July 2026).
• Picked for Neurology (clinical) (top studies of the week, 26 July 2026).

Abstract

BACKGROUND: Oral anticoagulation (OAC) and left atrial appendage closure (LAAC) are stroke prevention strategies for patients with atrial fibrillation. OBJECTIVES: To compare stroke and bleeding outcomes from a meta-analysis of randomized controlled trials comparing LAAC to OAC. METHODS: The primary outcome was stroke or systemic embolism (stroke/SE). Secondary outcomes included ischemic stroke, hemorrhagic stroke, major bleeding (MB), clinically significant bleeding (MB + clinically relevant nonmajor bleeding), non-procedure related clinically-significant bleeding, and cardiovascular or all-cause mortality. RESULTS: Seven randomized controlled trials met inclusion criteria (n = 7,353 patients; CHA2DS2-VASc score: 3.9; mean follow-up: 37.6 months), including 294 stroke/SE events. LAAC was similar to OAC for preventing stroke/SE (risk ratio [RR]: 1.10, 95% CI: 0.82-1.48). Clinically significant bleeding (RR: 0.60, 95% CI: 0.36-0.98) and non-procedure-related clinically significant bleeding (RR: 0.50, 95% CI: 0.39-0.64) were less frequent after LAAC. No statistically significant differences were observed for ischemic stroke, hemorrhagic stroke, MB, cardiovascular mortality, or all-cause mortality. The annualized incidence rate difference of stroke with LAAC did not increase with higher CHA2DS2-VASc scores and did not exceed 0.37%/year in any nonwarfarin-OAC comparative trial. In postablation patients, LAAC showed similar stroke/SE rates (RR: 0.92, 95% CI: 0.53-1.60; P-interaction = 0.76) and less nonprocedural clinically significant bleeding (RR: 0.51, 95% CI: 0.42-0.62; P-interaction = 0.56). CONCLUSIONS: LAAC prevents stroke/SE at rates not significantly different from OAC while reducing clinically significant bleeding, with possibly a more favorable benefit in postablation patients. In the full cohort, the numerically higher ischemic stroke rate was not statistically significant, and small in absolute terms. These findings support LAAC based on individualized, patient-centered decision-making, balancing stroke and bleeding risks.

Abstract as published, via PubMed.