Oral anticoagulation regimen after left atrial appendage occlusion in elderly atrial fibrillation patients with versus without cardiovascular comorbidities

Introduction

Antithrombotic therapy is used after left atrial appendage occlusion (LAAO) to prevent device-related thrombosis (DRT) that could lead to stroke or transient ischemic attack (TIA). Ageing in atrial fibrillation (AF) as well as many age-associated comorbidities are known risk factor for stroke. Moreover, bleeding risk is high in elderly patients on oral anticoagulation (OAC). Therefore, balancing the risk of bleeding and thromboembolic events is critical in older AF patients.

Objective

We aimed to assess the efficacy of half-dose of the direct oral anticoagulant (HD-DOAC) in preventing DRT and stroke while keeping the bleeding risk low in patients aged ≥75 years with vs without comorbidities such as diabetes, uncontrolled hypertension and heart failure.

Methods

Consecutive patients undergoing LAAO procedure were screened for those aged ≥75 years and these elderly patients were divided into two groups based on their comorbidity status. Group 1: No hypertension, diabetes or heart failure and Group 2: presence of ≥1 of the 3 above-mentioned conditions. All received HD-DOAC for 6 months after the LAAO procedure along with aspirin 81 mg followed by long-term HD-DOAC monotherapy. These patients were monitored for 1-year for DRT, Stroke/TIA and bleeding events. A total of 3 trans-esophageal echocardiography was performed at 1.5, 3 and 12-months post-procedure, to assess DRT.

Results

Of the 1636 AF patients undergoing LAAO procedure, 779 (47.6%) aged ≥75 years were included in this analysis (Group 1: 322 and Group 2: 457). In group 2, 214 (46.8%), 288 (63%) and 98 (21.4%) patients had diabetes, hypertension and heart failure respectively. HD-DOAC included apixaban 2.5 mg twice daily (n=568, 72.9%) or rivaroxaban 10 mg once a day (n=211, 27.1%). The median CHA2DS2-VASc score was 3 (IQR 2-4) and 4 (IQR: 3-6) in group 1 and 2 respectively.

At 1 year, stroke/TIA were reported in 3 (0.93%) and 5 (1.09) patients in group 1 and 2 respectively (p=0.82). Major bleeding events were comparable across groups (Group 1: 2 (0.62%); Group 2: 4 (0.87%); p=0.69). No DRT was detected in either group.

Conclusion

After successful Watchman implantation, long-term HD-DOAC is safe and effective in reducing the risk of DRT, stroke/TIA and bleeding events in elderly patients regardless of their comorbidity status.