LAAO Tied to Fewer Post-Fall Bleeds Than DOACs in AF

Left atrial appendage occlusion (LAAO) is associated with fewer injuries and less bleeding from falls than anticoagulant medications in patients with atrial fibrillation (AF) and a previous stroke, a new cohort study suggests.

Investigators prospectively followed more than 1250 patients with AF and a previous ischemic stroke. Approximately half underwent LAAO, while the other half were treated with direct oral anticoagulants (DOACs). Patients were followed for close to 2 years.

Slightly more than 20% of patients fell during that period in each group, and after their falls, patients on DOACs had significantly more severe injuries and longer hospital stays, compared with those treated by LAAO, who were not taking anticoagulants. The risk for a major bleed, including an intracranial bleed, was 70% lower in the LAAO group.

LAAO has previously been considered for people at risk of bleeding events — for example, those with gastrointestinal (GI) bleeds, bruising, or intracranial bleeding — but had not yet been studied in those at risk for falls, co-author Moussa Mansour, MD, professor of medicine, Harvard Medical School, and director of the Atrial Fibrillation Program at Massachusetts General Hospital, Boston, told theheart.org | Medscape Cardiology.

This is the first study to focus on LAAO specifically for those at risk for falling and demonstrated that the LAAO has utility in this population as well, which is important because the US population is an aging population, and at advanced ages, "people's balance becomes unsteady and they are at high risk of falling," he said.

The findings were published online as a research letter in the July 25 issue of the Journal of the American College of Cardiology.

Multidisciplinary Collaboration

"More than 1 in 5 of our neurology patients with AF fall — many with devastating consequences — making stroke prevention extremely challenging," senior author MingMing Ning, MD, MMsc, associate professor of neurology, Harvard Medical School, and director of the Cardio-Neurology and the Clinical Proteomics Research Center at Massachusetts General Hospital, Boston, told theheart.org | Medscape Cardiology.

"There is a dire need to tailor treatment to keep our patients safe while preventing future strokes," she said.

Anticoagulants are effective in stroke prevention in these patients but are associated with a higher risk for major bleeding, especially after a fall.

The current prospective observational study recruited 1266 stroke patients who were treated either with LAAO or DOACs (n = 570 and 696, respectively). Patients were followed for a median of 1.8 years (IQR: 0.9 - 3.0).

During the follow-up period, 22.6% of LAAO-treated patients and 22.7% of DOAC-treated patients sustained a fall (mean age 78.9 years, 57.4% male and 79.1 years, 52.5% male respectively).

Fall severity, evaluated using the Injury Severity Score, was less in the LAAO vs the DOAC group, with ISS scores of 1 (IQR 1 - 4) vs 4 (IQR 1.75 - 9).

Additionally, LAAO was associated with significantly reduced severity of fall-related injuries (OR: -1.09, 95% CI, -1.52 to -0.66; P < .001) — a finding that remained statistically significant even after adjusting for confounders such as age, sex, and comorbidities contributing to fall risk, such as hypertension, hyperlipidemia, and diabetes.

The incidence of major trauma (defined as ISS >15) was lower in the LAAO group, compared to the DOAC group (0.8% vs 6.3%, respectively, P = .026), and LAAO-treated patients had a shorter length of hospital stay, with fewer LAAO patients compared to DOAC patients staying in the hospital for more than 3 days (17% vs 29.1%, respectively, P = .018).

Importantly, the risk for major post-fall bleeding was lower in the LAAO vs the DOAC group (4.7% vs 15.2%, AOR, 0.29; 95% CI, 0.11 - 0.73; P = .009) — a finding that included intracranial bleeding (3.1% vs 9.5%; AOR, 0.29; 95% CI, 0.09 - 0.90; P = .033).

"Many people are living to advanced ages, where their balance becomes unsteady, and in addition, we have an increase in the prevalence of AF because people are living longer and it's a disease of the elderly, because we have more hypertension, and we also have more tools to diagnose AF. It's almost a 'perfect storm' situation, and we need effective interventions in this population," Mansour commented.

Before the study, people at risk for falling were not being considered for LAAO; but now, "we believe they should be considered," he added. "And although people in the current study had all experienced an ischemic stroke, any patient at risk of a fall will potentially benefit.”

Beyond demonstrating the role of LAAO in reducing the risk of post-fall bleeding injuries, the study — which was conducted by specialists in neurology and cardiology among other fields — highlights the importance of multidisciplinary collaboration, which is "key" for effective stroke prevention, Ning said.

She emphasized that "we need to learn from our patients and tailor treatment to their needs. A patient's risk of falling, lifestyle, and medication adherence are all important for individualizing care and improving quality of life."

Better Option

Commenting for theheart.org | Medscape Cardiology, Andrea Natale, MD, executive medical director, Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, said the authors "should be commended for this prospective study on real-world patients that has yielded highly meaningful data from a clinical standpoint."

Natale, who was not involved with the study, said it has "several strong points," such as a fairly large sample size, exclusive population with a history of AF-related stroke, long follow-up duration, evaluation of fall incidents by blinded experts, and severity of fall assessed by a validated questionnaire.

"This is the first study that directly compared the outcomes of traumatic fall in patients receiving LAAO vs OAC," he said. "Given that history of fall is an independent predictor of bleeding and death, the study findings by Deng et al offer the hope for a safer life with the LAAO option in the aging, fall-prone AF population."

The take-home message is that, in patients with history of stroke, LAAO "is a better option, in terms of significantly reduced injury severity and shortened hospital length of stay after traumatic falls," Natale said.

This study was supported in part by research grants from Boston Scientific, the Leducq Foundation, and the National Institutes of Health. The authors report no relevant financial relationships. Natale is a consultant for Abbott, Baylis, Biosense Webster, Biotronik, Boston Scientific, and Medtronic.

J Am Coll Cardiol. Published in the July 25, 2023 issue. Research Letter

Batya Swift Yasgur MA, LSW is a freelance writer with a counselling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).

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