Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation a randomized clinical trial

Vivek Y. Reddy, Horst Sievert, Jonathan Halperin, Shephal K. Doshi, Maurice Buchbinder, Petr Neuzil, Kenneth Huber, Brian Whisenant, Saibal Kar, Vijay Swarup, Nicole Gordon, David Holmes, David R. Holmes, Larry Chinitz, Pam Douglas, John Gurley, Peter Sick, Zoltan G. Turi, Stephen T. Hustead, Richard W. AsingerWendy Shear, Brian Lew, Anthony Plucinski, Eve Rogers, Sven Mobius-Winkler, Kelly Tucker, Shephal Doshi, Marwan Bahu, Ramon Quesada, Vivek Reddy, Steven Almany, Ashok Garg, Gregory Mishkel, Stephen Ramee, Brijeshwar Maini, Steven Burstein, Rodney Horton, Paul Mahoney, Stuart Adler, Kimberly Skelding, Miland Shah, Steven Yakubov, Angel Leon, Peter C. Block, Peter Fail, Mark Reisman, Gery Tomassoni, Vishwajeth Bhoopalam, William Anderson, Robert Pickett, PROTECT AF Steering Committee and Investigators

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401 Scopus citations


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 AFwas 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 (CHADS2score≥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.

Original languageEnglish (US)
Pages (from-to)1988-1998
Number of pages11
JournalJAMA - Journal of the American Medical Association
Issue number19
StatePublished - Nov 19 2014

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