Do Improvements in Anticoagulation Therapy Obviate the Need for Left Atrial Appendage Occlusion Therapies?

Oral anticoagulation is the standard of care for stroke prevention in atrial fibrillation but falls short of providing an adequate solution to this common threat when considered from both efficacy and safety perspectives. Anticoagulationassociated treatment deficits include major and minor bleeding, refusal of anticoagulation based on anticoagulation risk, lack of medication adherence, personal and physician preference, and a persistent risk of ischemic stroke and major adverse cardiovascular events despite use. The challenges of contemporary anticoagulation management are highlighted in a recent large national assessment of warfarin therapy use involving 138 319 patients and 2 683 674 international normalized ratio results with reported mean time in therapeutic range of only 53.7%. Even in the setting of optimal management without clinically relevant major bleeds, emerging data regarding long-term risk of cerebral microbleeds prompt the need to explore risk and benefits of long-term anticoagulation use in patients with atrial fibrillation.