Reduced Dose-Direct Oral Anticoagulant Vs Dual Antiplatelet Therapy After Left Atrial Appendage Closure in Patients With Nonvalvular Atrial Fibrillation: A Systematic Review and Meta Analysis.

BACKGROUND

Reduced-dose direct oral anticoagulants (DOACs) are increasingly used after left atrial appendage closure (LAAC) in nonvalvular atrial fibrillation (NVAF), but their benefit over dual antiplatelet therapy (DAPT) remains uncertain.

OBJECTIVE

To evaluate the efficacy, safety, and net clinical benefit of reduced-dose DOAC versus DAPT following percutaneous LAAC in adults with NVAF.

METHODS

A systematic review and meta-analysis of randomized controlled trials and observational cohorts comparing reduced-dose DOAC (apixaban 2.5 mg twice daily or rivaroxaban 10-15 mg once daily) with DAPT after successful LAAC in adults (≥18 years) with NVAF was conducted by searching PubMed, Embase, Scopus, Cochrane CENTRAL, and ClinicalTrials.gov from inception through February 2026. Dichotomous outcomes were pooled as risk ratios (RRs) with 95% confidence intervals (CIs) using random-effects models; heterogeneity was assessed with I² and χ² statistics. Analyses were performed with RevMan 5.4.

RESULTS

Seven studies (3 randomized controlled trials, 4 cohorts) including 2126 patients (reduced-dose DOAC = 1088; DAPT = 1038) were analyzed. Reduced-dose DOAC significantly reduced composite thromboembolic events (RR = 0.20, 95% CI = 0.10-0.39; I² = 0%), ischemic stroke (RR = 0.33, 95% CI = 0.13-0.80; I² = 0%), and device-related thrombosis (RR = 0.33, 95% CI = 0.18-0.60; I² = 0%) compared with DAPT. The net clinical benefit composite (thromboembolism plus major bleeding) favored reduced-dose DOAC (RR = 0.36, 95% CI = 0.19-0.70; I² = 63%), with apixaban-predominant subgroups showing strongest effects (RR = 0.14, 95% CI = 0.05-0.36). Major bleeding was lower (RR = 0.54, 95% CI = 0.35-0.83; I² = 0%), any bleeding reduced (RR = 0.52, 95% CI = 0.30-0.88; I² = 64%), and minor bleeding trended lower (RR = 0.66, 95% CI = 0.42-1.02; I² = 34%), whereas cardiovascular (RR = 0.66, 95% CI = 0.23-1.92) and all-cause mortality (RR = 0.74, 95% CI = 0.42-1.30) did not differ significantly between groups.

CONCLUSION AND RELEVANCE: Reduced-dose DOAC therapy after LAAC lowered thromboembolic events, device-related thrombosis, and major bleeding versus DAPT, without affecting mortality. These findings support consideration of reduced-dose DOACs, especially apixaban-based regimens, in appropriately selected patients.