Stroke prevention is the primary goal of therapy in patients with atrial fibrillation (AF).1 Heart has published numerous papers on early AF detection,2 approaches for restoring normal sinus rhythm, risk scores for determining which AF patients benefit most from anti-thrombotic therapy, and transcatheter occlusion of the left atrial appendage (LAA) to prevent thrombus formation.3–6 Early studies of LAA occlusion compared this procedure to vitamin K antagonist (VKA) therapy for stroke prevention. Now, direct oral anticoagulants (DOACs) have replaced VKA therapy in many AF patients due to an improved risk/benefit profile, among other advantages, but LAA occlusion has not been compared to DOAC therapy.

In this issue of Heart, Sahay and colleagues (see page 139) performed a network meta-analysis of the efficacy and safety of LAA occlusion compared to medical therapy based on 19 randomized trials (including over 87 thousand patients) that compared VKA with placebo, anti-platelet therapy (APT) or a DOAC. Outcomes in 2 major trials of LAA occlusion then were indirectly compared to the network meta-analysis of medical therapy, using VKA therapy as the reference standard (figure 1). The authors conclude that LAA occlusion is more beneficial than placebo or APT and similar in efficacy to DOAC therapy.