SOURCE: Reddy VY, et al. Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: A randomized clinical trial. JAMA 2014;312:1988-1998.
The most feared consequence of atrial fibrillation is stroke, which most commonly results from a thrombus generated in the left atrial appendage (LAA). Warfarin and novel anticoagulant agents are highly efficacious, reducing the risk of stroke by as much as 66%, but warfarin requires close follow-up and has a narrow therapeutic range. Although novel anticoagulants do not require monitoring, bleeding risk is still an important obstacle. If most atrial fibrillation-related strokes are due to thrombus formed in the LAA, might mechanical closure of the LAA prevent stroke and diminish or eliminate the need for anticoagulation?
Reddy et al report on the results of the PROTECT AF clinical trial, which randomized atrial fibrillation patients (n = 707) to LAA closure or “traditional” warfarin treatment (LAA closure patients did not receive warfarin).
The primary endpoint of the study was a composite of stroke, systemic embolism, or cardiovascular death. At a mean of 3.8 years of follow-up, LAA closure was found to be non-inferior to warfarin treatment, and the warfarin treatment group had been well-managed (time in therapeutic range = 70%). LAA closure may be another reasonable option for reduction of stroke risk in atrial fibrillation.