Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.
Curitiba Heart Institute, Curitiba, Brazil.
J Am Coll Cardiol. 2023 Oct 31;82(18):1765-1773. doi: 10.1016/j.jacc.2023.08.010. Epub 2023 Aug 21.
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.
在非瓣膜性心房颤动（AF）患者中，左心耳封堵（LAAO）后最佳的抗血栓治疗仍不确定。
本研究旨在比较 LAAO 后各种抗血栓策略的疗效和安全性。
我们检索了 Medline、Cochrane、EMBASE、LILACS 和 ClinicalTrials.gov 数据库，以获取报告 LAAO 后结局的研究，按术后出院时规定的抗血栓治疗进行分层。直接口服抗凝剂（DOAC）、维生素 K 拮抗剂（VKA）、单一抗血小板治疗（SAPT）、双重抗血小板治疗（DAPT）、DOAC 加 SAPT、VKA 加 SAPT 和无抗血栓治疗进行了分析。我们使用固定效应模型网络荟萃分析来估计每个比较的优势比（OR）和 95%置信区间（CI）。P 评分提供了治疗方案的排名。
纳入了 41 项研究，共包括 12451 例非瓣膜性 AF 患者。DAPT、DOAC、DOAC 加 SAPT 和 VKA 显著优于无治疗以预防器械相关血栓形成。与 VKA 相比，DOAC 与较低的全因死亡率相关（OR：0.39；95%CI：0.17-0.89；P=0.03）。与 SAPT 相比，DAPT 与较少的血栓栓塞事件相关（OR：0.50；95%CI：0.29-0.88；P=0.02），但大出血无差异。在 P 评分分析中，DOAC 单药治疗是最有可能降低血栓栓塞事件和大出血的策略。
在这项比较 LAAO 后初始抗血栓治疗的网络荟萃分析中，DOAC 单药治疗发生血栓栓塞事件和大出血的可能性最低。与 SAPT 相比，DAPT 与较低的血栓栓塞事件发生率相关，在不能耐受抗凝的患者中可能是首选。
