Physician’s WeeklyStandard Therapy Outperforms LAA Closure in High-Risk AF

CLOSURE-AF trial shows catheter-based LAA closure failed to match standard anticoagulation therapy in 912 high-risk AF patients (mean age 78). The device missed noninferiority for composite outcomes including stroke, bleeding, and cardiovascular death after 3-year follow-up across 42 German centers.

🔬 CLINICAL CONSIDERATIONS

• LAA closure missed noninferiority threshold despite sealing the primary AF thrombus site. Standard anticoagulation provided superior composite endpoint protection in this elderly, high-risk population.
• Bleeding concerns driving LAA referrals may be overweighted in clinical decision-making. Oral anticoagulation demonstrated strong net clinical benefit even in patients with elevated bleeding risk scores and documented bleeding histories.
• Trial enrolled exceptionally high-risk population with mean age 78 and elevated CHA₂DS₂-VASc and HAS-BLED scores. Results should not be generalized to younger patients or moderate-risk AF cohorts where device outcomes may differ.
• Procedural alternative failed where pharmacologic therapy succeeded in largest LAA closure trial to date. This challenges the assumption that device-based stroke prevention equals or surpasses guideline-directed medical therapy.
• Study represents paradigm shift for high-risk elderly AF management. Prior expectations that LAA closure would prove comparable to anticoagulation were not supported by trial evidence in this vulnerable population.

🎯 PRACTICE APPLICATIONS

• Maintain anticoagulation as first-line therapy for high-risk elderly AF despite bleeding history concerns
• Document CLOSURE-AF findings when patients request LAA closure based on bleeding fear narratives from media
• Reserve LAA closure for absolute anticoagulation contraindications, not relative bleeding risk elevation or patient preference
• Counsel patients that procedural alternatives have not proven superior to optimized medical management in rigorous trials

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