From the Guidelines
For patients with atrial fibrillation who have contraindications to anticoagulation therapy, left atrial appendage occlusion (LAAO) devices, such as the Atriclip, represent a viable alternative for stroke prevention.
Alternatives to Anticoagulation
When considering alternatives to long-term anticoagulation for stroke prevention in patients with atrial fibrillation (AF) and contraindications to anticoagulation, several options can be evaluated. These include:
- Left atrial appendage occlusion (LAAO) devices
- Antiplatelet therapy with aspirin or dual antiplatelet therapy with aspirin plus clopidogrel
- Rate and rhythm control strategies
Left Atrial Appendage Occlusion (LAAO) Devices
LAAO devices, such as the Atriclip, are designed to physically close off the left atrial appendage, where most stroke-causing clots form in AF patients. This procedure is typically performed once via cardiac catheterization and requires only short-term antiplatelet therapy afterward. According to the 2024 ESC guidelines for the management of atrial fibrillation 1, stand-alone endoscopic surgical closure of the left atrial appendage may be considered in patients with AF and contraindications for long-term anticoagulant treatment to prevent ischemic stroke and thromboembolism.
Antiplatelet Therapy
Antiplatelet therapy with aspirin (81-325 mg daily) may be used, though it is significantly less effective than anticoagulants, reducing stroke risk by only about 20% compared to 60-70% with anticoagulants. Dual antiplatelet therapy with aspirin plus clopidogrel (75 mg daily) offers somewhat better protection than aspirin alone but still remains inferior to anticoagulation and carries increased bleeding risk 1.
Rate and Rhythm Control Strategies
Rate and rhythm control strategies, including medications like beta-blockers, calcium channel blockers, or antiarrhythmic drugs, along with procedures such as cardioversion or catheter ablation, may reduce stroke risk by addressing the underlying arrhythmia but are generally considered complementary rather than primary stroke prevention approaches.
Recommendation
The use of LAAO devices, such as the Atriclip, is recommended for patients with AF and contraindications to anticoagulation therapy, as they offer a viable alternative for stroke prevention 1. These alternatives should be carefully selected based on individual patient factors, including the specific contraindication to anticoagulation, overall bleeding risk, and patient preferences.
From the Research
Alternatives to Long-Term Anticoagulation for Stroke Prevention in Atrial Fibrillation
- Left atrial appendage (LAA) closure has emerged as a mechanical alternative to pharmacologic stroke prevention in patients with atrial fibrillation (AF) and contraindications to anticoagulation 2, 3, 4, 5.
- LAA closure devices, such as the WATCHMAN family, have been shown to be safe and effective in reducing the risk of stroke in patients with non-valvular AF 3, 4.
- The procedure involves closing off the left atrial appendage, which is a common source of thromboembolism in patients with AF 2, 4, 5.
- Patient selection for LAA closure is crucial, and typical candidates include those with prior intracranial bleeding or recurrent serious bleeding who are not eligible for long-term oral anticoagulation 2, 3.
Benefits and Risks of LAA Closure
- LAA closure has been shown to have a net clinical benefit that appears to be non-inferior to oral anticoagulation, with less intracranial bleeding 2.
- However, concern remains over the possible increased risk of ischemic stroke in long-term follow-up 2, 3.
- Device-related thrombosis, post-treatment antithrombotic therapy, and peri-device leakage are also potential risks associated with LAA closure 3, 5.
Ongoing Research and Future Directions
- Clinical investigation and randomized trials are needed to clarify the best methods of LAA occlusion, optimal pharmacologic strategies in the short-term after LAA closure, and to identify patient populations who will derive the most benefit from LAA occlusion 2, 6, 5.
- Ongoing studies are assessing the usefulness of LAA closure in both primary and secondary stroke prevention for patients with AF, including those with high risk of bleeding 6, 5.