Dual Antiplatelet Therapy Versus Direct Oral Anticoagulation in High‐Risk Patients Undergoing Left Atrial Appendage Occlusion With Watchman FLX
Year: 2026
Type: article
Abstract: Background Optimal antithrombotic therapy after left atrial appendage occlusion remains uncertain. Methods We studied 2817 patients undergoing left atrial appendage occlusion at 8 hospitals from 2016 to 2023 using registry data linked to Medicare claims. Among 2448 Watchman FLX recipients, the primary exposure was time‐varying dual antiplatelet therapy (DAPT) versus pooled direct oral anticoagulant (DOAC)‐based therapy. Outcomes were major adverse cardiovascular events (MACE), major bleeding, and device complications. The primary instrumental‐variable analysis used operator FLX preference; overlap weighting was secondary and pairwise regimen comparisons exploratory. Results DAPT was associated with lower MACE (absolute risk difference [ARD], −1.5% [95% CI, −1.9% to −1.0%]; number needed to treat, 67) and major bleeding (ARD −1.6% [95% CI, −2.0% to −0.9%]; number needed to treat, 63) than pooled DOAC‐based therapy, without increased device complications. Overlap‐weighted associations with MACE and major bleeding were nonsignificant. In exploratory pairwise analyses, DAPT did not differ significantly from DOAC monotherapy for MACE or major bleeding; lower major bleeding was limited to DAPT versus DOAC plus single antiplatelet therapy (ARD, −0.6% [95% CI, −1.1% to −0.2%]; P =0.008). Most estimated benefit accrued within 6 months. Conclusions DAPT was associated with lower MACE and major bleeding than pooled DOAC‐based therapy after Watchman FLX implantation. The safety benefit was concentrated in the comparison with DOAC + single antiplatelet therapy, whereas DAPT and DOAC monotherapy did not clearly differ in either outcome. These findings support randomized trials comparing DAPT with DOAC monotherapy.
Institutions: HCA Healthcare, Kaiser Permanente, Northside Hospital
Language: English
Subfield: Cardiology and Cardiovascular Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,810
OpenAlex ID: W7225855538