Left atrial appendage occlusion versus antithrombotic therapy in nonvalvular AF with ASCVD and prior embolism

Managing nonvalvular atrial fibrillation (NVAF) in patients with atherosclerotic cardiovascular disease (ASCVD) and prior embolism is challenging. This retrospective study evaluated long-term outcomes of left atrial appendage occlusion (LAAO) compared with oral anticoagulation (OAC) and antiplatelet therapy (APT) in primary ( n = 647) and external validation ( n = 570) cohorts. The primary composite outcome included recurrent ischemic stroke or systemic embolism, major bleeding, and all-cause mortality. After inverse probability of treatment weighting (IPTW), risks of the primary outcome, major bleeding, and mortality for LAAO were comparable with or lower than those of OAC and APT. For recurrent embolism, competing-risk analyses showed both OAC (SHR = 3.578, p = 0.003) and APT (SHR = 2.494, p = 0.040) carried a higher risk than LAAO. Results were consistent in the external validation cohort. These findings suggest LAAO may be a reasonable option for this high-risk population, offering a lower risk of recurrent embolism and comparable risk of major bleeding relative to pharmacological therapies.