Cited by 1,018Atrial Fibrillation Management and OutcomesCardiovascular and Diving-Related ComplicationsAcute Ischemic Stroke Management

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Percutaneous Left Atrial Appendage Closure vs Warfarin for Atrial Fibrillation: A Randomized Clinical Trial

Reddy, Vivek Y., Sievert, Horst, Halperin, Jonathan, Doshi, Shephal K., Buchbinder, Maurice, Neuzil, Petr, Huber, Kenneth, Whisenant, Brian, Kar, Saibal, Swarup, Vijay, Gordon, Nicole, Holmes, David·2014·JAMA

DOI 10.1001/jama.2014.15192

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Abstract

IMPORTANCE: While effective in preventing stroke in patients with atrial fibrillation (AF), warfarin is limited by a narrow therapeutic profile, a need for lifelong coagulation monitoring, and multiple drug and diet interactions. OBJECTIVE: To determine whether a local strategy of mechanical left atrial appendage (LAA) closure was noninferior to warfarin. DESIGN, SETTING, AND PARTICIPANTS: PROTECT AF was a multicenter, randomized (2:1), unblinded, Bayesian-designed study conducted at 59 hospitals of 707 patients with nonvalvular AF and at least 1 additional stroke risk factor (CHADS2 score ≥1). Enrollment occurred between February 2005 and June 2008 and included 4-year follow-up through October 2012. Noninferiority required a posterior probability greater than 97.5% and superiority a probability of 95% or greater; the noninferiority margin was a rate ratio of 2.0 comparing event rates between treatment groups. INTERVENTIONS: Left atrial appendage closure with the device (n = 463) or warfarin (n = 244; target international normalized ratio, 2-3). MAIN OUTCOMES AND MEASURES: A composite efficacy end point including stroke, systemic embolism, and cardiovascular/unexplained death, analyzed by intention-to-treat. RESULTS: At a mean (SD) follow-up of 3.8 (1.7) years (2621 patient-years), there were 39 events among 463 patients (8.4%) in the device group for a primary event rate of 2.3 events per 100 patient-years, compared with 34 events among 244 patients (13.9%) for a primary event rate of 3.8 events per 100 patient-years with warfarin (rate ratio, 0.60; 95% credible interval, 0.41-1.05), meeting prespecified criteria for both noninferiority (posterior probability, >99.9%) and superiority (posterior probability, 96.0%). Patients in the device group demonstrated lower rates of both cardiovascular mortality (1.0 events per 100 patient-years for the device group [17/463 patients, 3.7%] vs 2.4 events per 100 patient-years with warfarin [22/244 patients, 9.0%]; hazard ratio [HR], 0.40; 95% CI, 0.21-0.75; P = .005) and all-cause mortality (3.2 events per 100 patient-years for the device group [57/466 patients, 12.3%] vs 4.8 events per 100 patient-years with warfarin [44/244 patients, 18.0%]; HR, 0.66; 95% CI, 0.45-0.98; P = .04). CONCLUSIONS AND RELEVANCE: After 3.8 years of follow-up among patients with nonvalvular AF at elevated risk for stroke, percutaneous LAA closure met criteria for both noninferiority and superiority, compared with warfarin, for preventing the combined outcome of stroke, systemic embolism, and cardiovascular death, as well as superiority for cardiovascular and all-cause mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00129545.

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Authors: Reddy, V. Y., Sievert, H., Halperin, J., Doshi, S. K., Buchbinder, M., Neuzil, P., Huber, K., Whisenant, B., Kar, S., Swarup, V., Gordon, N., & Holmes, D.
Affiliations: Na Homolce Hospital (CZ)
Cardiovascular Center Frankfurt (DE)
Icahn School of Medicine at Mount Sinai (US)
Saint John's Health Center (US)
Foundation for Cardiovascular Medicine, La Jolla, California
Homolka Hospital, Prague, Czech Republic
Saint Luke's Hospital (US)
Intermountain Medical Center (US)
Cedars-Sinai Medical Center (US)
Arizona Heart Rhythm Center, Scottsdale
Boston Scientific (United States) (US)
Mayo Clinic (US)
Corresponding author: Reddy, Vivek Y.
ORCID: Reddy, Vivek Y.
Halperin, Jonathan
Doshi, Shephal K.
Buchbinder, Maurice
Whisenant, Brian
Kar, Saibal
Holmes, David
Venue: JAMA
Publisher: American Medical Association (AMA)
Published: 2014-11-19
Volume: 312
Issue: 19
Pages: 1988
ISSN: 0002-9955 (ISSN-L)
0098-7484
DOI: 10.1001/jama.2014.15192
OpenAlex: W2112970567
Cited by: 1,018
References: 25
Citations by year: 2026: 73 · 2025: 86 · 2024: 87 · 2023: 102 · 2022: 97 · 2021: 84 · 2020: 75 · 2019: 58 · 2018: 87 · 2017: 104 · 2016: 75 · 2015: 77 · 2014: 6
FWCI: 59.90
Type: journal article
Language: en
Open access: closed
Locations: JAMA (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cardiovascular and Diving-Related Complications
Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
Keywords: left atrial appendage closure, warfarin, atrial fibrillation, stroke prevention, systemic embolism, cardiovascular mortality, non-inferiority, non-valvular atrial fibrillation, CHADS2 score, anticoagulation, international normalized ratio, bleeding complications, quality of life, patient satisfaction, patient-reported outcomes
MeSH terms: Aged, Aged, 80 and over, Anticoagulants, Atrial Fibrillation, Bayes Theorem, Cardiovascular Diseases, Embolism, Female, Cardiac Catheterization, Humans, Male, Middle Aged, Risk Factors, Warfarin, Survival Analysis, Treatment Outcome, Prosthesis Implantation, Atrial Appendage, Stroke

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Percutaneous Left Atrial Appendage Closure vs Warfarin for Atrial Fibrillation: A Randomized Clinical Trial

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