Left Atrial Appendage Closure Versus Oral Anticoagulation for Prevention of Stroke or Systemic Embolism in Patients With Atrial Fibrillation: An Updated Meta-Analysis of 7004 Patients Across Six Randomized Trials

INTRODUCTION: Left atrial appendage closure (LAAC) is an emerging alternative for stroke prevention in patients with atrial fibrillation (AF) who are unsuitable for long-term oral anticoagulants (OACs). However, its efficacy and safety relative to OACs remain uncertain. METHODS: Three databases were searched up to April 7, 2026, for randomized controlled trials comparing LAAC with OAC in patients with AF. Risk ratios with 95% confidence intervals were pooled using a random-effects model. RESULTS: Six RCTs (n = 7004 patients) were analyzed. The risk of stroke or systemic embolism (SSE) did not differ significantly between the LAAC and OAC groups (RR: 1.10 [0.87-1.39]; p = 0.42). The risk of ischemic SSE was significantly increased with LAAC (RR: 1.41 [1.07-1.85]; p = 0.02) compared with OAC. No significant differences were observed in all-cause mortality (RR: 0.94 [0.81-1.09]), cardiovascular mortality (RR: 0.91 [0.69-1.21]), non-cardiovascular mortality (RR: 0.91 [0.75-1.12]), or hemorrhagic stroke (RR: 0.58 [0.29-1.17]). LAAC was associated with a similar risk of overall major bleeding (RR: 0.92 [0.77-1.09]) and low risk of non-procedural bleeding (RR: 0.61 [0.52-0.73]; p < 0.001) compared with OAC. Upon sensitivity analysis comparing LAAC with DOACs, the findings remained consistent across most clinical outcomes. CONCLUSION: LAAC demonstrates comparable risks of SSE and major bleeding to OACs, but is associated with a higher risk of ischemic SSE and reduced non-procedural bleeding, supporting its use in selected patients at high risk for long-term bleeding while emphasizing individualized shared decision-making.