Left Atrial Appendage Closure Versus Oral Anticoagulation for Prevention of Stroke or Systemic Embolism in Patients With Atrial Fibrillation: An Updated Meta-Analysis of 7004 Patients Across Six Randomized Trials.

INTRODUCTION Left atrial appendage closure (LAAC) is an emerging alternative for stroke prevention in patients with atrial fibrillation (AF) who are unsuitable for long-term oral anticoagulants (OACs). However, its efficacy and safety relative to OACs remain uncertain.

Methods

Three databases were searched up to April 7, 2026, for randomized controlled trials comparing LAAC with OAC in patients with AF. Risk ratios with 95% confidence intervals were pooled using a random-effects model.

Results

Six RCTs (n = 7004 patients) were analyzed. The risk of stroke or systemic embolism (SSE) did not differ significantly between the LAAC and OAC groups (RR: 1.10 [0.87-1.39]; p = 0.42). The risk of ischemic SSE was significantly increased with LAAC (RR: 1.41 [1.07-1.85]; p = 0.02) compared with OAC. No significant differences were observed in all-cause mortality (RR: 0.94 [0.81-1.09]), cardiovascular mortality (RR: 0.91 [0.69-1.21]), non-cardiovascular mortality (RR: 0.91 [0.75-1.12]), or hemorrhagic stroke (RR: 0.58 [0.29-1.17]). LAAC was associated with a similar risk of overall major bleeding (RR: 0.92 [0.77-1.09]) and low risk of non-procedural bleeding (RR: 0.61 [0.52-0.73]; p < 0.001) compared with OAC. Upon sensitivity analysis comparing LAAC with DOACs, the findings remained consistent across most clinical outcomes.

Conclusion

LAAC demonstrates comparable risks of SSE and major bleeding to OACs, but is associated with a higher risk of ischemic SSE and reduced non-procedural bleeding, supporting its use in selected patients at high risk for long-term bleeding while emphasizing individualized shared decision-making.