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Life sciences · Journal article
JAMA Cardiology · August 26, 2026
Well-designed and adequately powered for the question it asks.
This meta-analysis of 8 RCTs found that catheter-based LAAC and oral anticoagulation achieved similar rates of overall stroke and major bleeding over long-term follow-up in patients with AF. However, LAAC was associated with a higher risk of ischemic stroke and lower risk of nonprocedural major bleeding, and the analysis does not support LAAC as a first-line alternative to OAC for stroke prevention in this population.
Systematic review and meta-analysis of randomized controlled trials. Patients with atrial fibrillation at high risk of stroke randomized to either catheter-based LAAC or oral anticoagulation in eligible trials. Intervention: Catheter-based left atrial appendage closure (LAAC). Compared with: Oral anticoagulation (OAC). n = 7,434. Eight trials; specific geographic distribution not stated in abstract.
No significant difference in overall stroke: IRR 1.08 (95% CI 0.82–1.41) for LAAC vs OAC No significant difference in major bleeding: IRR 0.96 (95% CI 0.81–1.14) for LAAC vs OAC LAAC associated with higher ischemic stroke risk: IRR 1.34 (95% CI 1.01–1.77) compared with OAC
No significant difference in major bleeding: IRR 0.96 (95% CI 0.81–1.14) for LAAC vs OAC LAAC associated with lower nonprocedural major bleeding: IRR 0.73 (95% CI 0.58–0.92) compared with OAC
Clinicians should continue to consider oral anticoagulation as the preferred first-line strategy for stroke prevention in AF patients at moderate to high risk, as LAAC does not offer advantages over OAC in overall stroke prevention and may increase ischemic stroke risk despite reducing nonprocedural bleeding. LAAC may warrant consideration only in selected patients with specific contraindications to anticoagulation.
High-quality meta-analysis of 8 RCTs with 7434 patients and 37.9-month follow-up reporting hard clinical endpoints (stroke, major bleeding) with precise effect estimates and confidence intervals, demonstrating no superiority of LAAC over OAC and a higher ischemic stroke risk.
As stated by the source record.
Quoted from the source exactly as published.
Clinicians should continue to consider oral anticoagulation as the preferred first-line strategy for stroke prevention in AF patients at moderate to high risk, as LAAC does not offer advantages over OAC in overall stroke prevention and may increase ischemic stroke risk despite reducing nonprocedural bleeding. LAAC may warrant consideration only in selected patients with specific contraindications to anticoagulation.
Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.
Importance: In patients with atrial fibrillation (AF), oral anticoagulation (OAC) is the gold standard for preventing ischemic stroke, at the expense of a higher risk of bleeding. Catheter-based left atrial appendage closure (LAAC) has been proposed as an alternative strategy to prevent stroke, but the efficacy and safety compared to OAC are uncertain. Objective: To evaluate the efficacy and safety of catheter-based LAAC compared to OAC in patients with AF at high risk of stroke. Data Sources: PubMed, Cochrane Central, and Web of Science were screened up to March 2026. The websites of leading cardiology societies, news outlets, and reference lists of each eligible study were also inspected. Study Selection: Studies enrolling patients with AF randomly assigned to catheter-based LAAC or OAC and reporting at least 1 outcome of interest were included. Data Extraction and Synthesis: Two investigators independently extracted data of interest and assessed data quality. Catheter-based LAAC vs OAC comparisons were pooled as incidence rate ratios (IRRs) using a frequentist random-effect model. Main Outcomes and Measures: Primary and coprimary outcomes were long-term stroke and major bleeding. Secondary outcomes included the composite of cardiovascular death, stroke, or systemic embolism, all-cause death, the single components of the composite end point, ischemic stroke, hemorrhagic stroke, and nonprocedural major bleeding. Periprocedural events (ie, stroke, major bleeding, death, device embolization, and pericardial effusion) were also combined. Results: Eight trials (7434 patients) were included in the meta-analysis. After a weighted mean follow-up of 37.9 months, no significant differences were detected for stroke (IRR, 1.08; 95% CI, 0.82-1.41) and major bleeding (IRR, 0.96; 95% CI, 0.81-1.14). However, catheter-based LAAC was associated with a higher risk of ischemic stroke (IRR, 1.34; 95% CI, 1.01-1.77) and a lower risk of nonprocedural major bleeding (IRR, 0.73; 95% CI, 0.58-0.92) compared with OAC. Periprocedural events per 1000 patients were 5 strokes, 9 episodes of bleeding, 1 death, 5 episodes of device embolization, and 9 pericardial effusions. Conclusions and Relevance: In patients with AF, at long-term follow-up, transcatheter LAAC was associated with similar rates of any type of stroke and major bleeding compared with OAC, while increasing the risk of ischemic stroke and lowering the risk of nonprocedure-related major bleeding. These findings do not support the routine use of LAAC as a first-line strategy for stroke prevention in patients with AF at moderate to high risk of stroke.
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