Taking a closer look at stroke prevention in atrial fibrillation
· Medical Xpressedited by Sadie Harley, reviewed by Andrew Zinin
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Patients with atrial fibrillation (AF), one of the most common heart rhythm disorders, are at increased risk of ischemic stroke, a stroke caused by a blood clot blocking blood flow to the brain, as well as blood clots that can travel to other parts of the body.
The primary treatment to reduce this risk is anticoagulation, or blood-thinning medication, but many patients cannot or choose not to take these medications. In recent years, several clinical trials have evaluated a procedure called left atrial appendage closure (LAAC), which seals off a small pouch in the heart where blood clots often form in patients with AF. The goal is to reduce stroke risk, potentially avoid long-term use of blood thinners and lower bleeding risk.
However, these trials have been interpreted in very different ways. Some experts believe LAAC should be widely adopted, while others have urged caution, including some insurers that have stopped covering the procedure.
Trials resist simple comparisons
Several groups have attempted to combine the results of available studies through meta-analyses to better understand the evidence. While these analyses were methodologically sound, the researchers found that the studies included patients and treatments that were different enough that combining their results did not represent a clearly defined patient population.
Therefore, a research team sought to provide a more balanced and comprehensive picture of the overall evidence in this evolving field.
For a JACC special communication, the researchers conducted a rigorous review of the literature and, for studies that met the selection criteria, provided an objective summary and interpretation of the findings. The team paid particular attention to important differences among the studies, including the types of patients involved, the LAAC procedures studied, the treatments LAAC was compared with and the outcomes the researchers measured.
For example, one might assume that LAAC eliminates the need for blood thinners. In reality, the situation is much more complex because blood clots can potentially form on these devices or elsewhere in the body.
In addition, nearly all of the trials used what is known as a "non-inferiority" design. Rather than determining whether one treatment is better than another, these studies are designed to determine whether a new treatment is not substantially worse than the treatment it is being compared with. These studies can be challenging to interpret and require careful consideration of potential biases.
Widespread use, limited randomized evidence
The investigators found a significant gap between how widely LAAC has been used and the amount of randomized clinical trial evidence available to support it. Although AF affects nearly 60 million people worldwide and more than 600,000 LAAC procedures have been performed globally, the randomized clinical trial evidence is based on just over 7,000 patients.
Within this relatively limited evidence base, there are important differences among the patients, treatments and study designs across trials, making it difficult to reliably combine their results.
Many trials also compared LAAC with treatments that are now considered outdated, such as the older blood thinner warfarin. Others included outcomes or study designs that made it more difficult to determine whether LAAC performed as well as the treatments it was compared with.
Some studies also raised concerns about potential harms, including an increased risk of blood clots in the veins after patients stopped taking anticoagulants following LAAC. The team also identified important gaps in knowledge and proposed a practical framework to help clinicians and patients navigate treatment decisions while additional evidence is gathered.
Weighing LAAC against stronger medication evidence
LAAC may be a valuable option for some patients with AF who are seeking to reduce their risk of stroke or other complications caused by blood clots. However, at this time, the evidence supporting anticoagulant medications remains considerably stronger. LAAC also comes with upfront costs and risks associated with undergoing the procedure, which may be especially important for frail patients or those with complex medical conditions.
As researchers await more robust data, treatment decisions should involve careful discussions between patients and specialists who perform LAAC, as well as those who manage AF without procedures. These conversations can help patients understand the potential benefits and risks and make decisions that align with their individual health needs, values and preferences.
While LAAC is not appropriate for everyone with AF, it may be a reasonable option for carefully selected patients.
More information
Behnood Bikdeli et al., Left Atrial Appendage Closure or Anticoagulation for Atrial Fibrillation, JACC (2026). DOI: 10.1016/j.jacc.2026.09.018
Key medical concepts
Atrial FibrillationIschemic Stroke
Clinical categories
CardiologyCommon illnesses & PreventionNeurology Provided by Mass General Brigham Who's behind this story?
Sadie Harley
BSc Life Sciences & Ecology. Microbiology lab background with pharmaceutical news experience in oil, gas, and renewable industries. Full profile →
Andrew Zinin
Master's in physics with research experience. Long-time science news enthusiast. Plays key role in Science X's editorial success. Full profile →
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