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A Decision Analysis of Left Atrial Appendage Closure as an Alternative to Long-Term Anticoagulation in a Health System's Patients with Atrial Fibrillation

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2018, MS, University of Cincinnati, Medicine: Clinical and Translational Research.
Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia and the most powerful risk factor for thromboembolic stroke accounting for 15% of all stroke cases. For patients with both a high risk for ischemic stroke, a high bleeding risk, and a contraindication for long-term oral anticoagulant therapy, treatment options have been limited. For those patients a left atrial appendage closure (LAAC) device (WatchmanTM) was recently approved by the FDA as a treatment option. Our group has created a Markov state-transition decision analytic model that examines strategies for optimal thromboprophylaxis of patients with AF. We hypothesized that the addition of a LAAC treatment strategy and pilot testing the updated model using patient-specific data from the UC Health system’s cohort of AF patients would allow us to 1) determine which, if any, patients would have LAAC as their optimal treatment and 2) analyze the characteristics of these patients to elucidate any common factors and conduct sensitivity analyses on these influential factors. Methods: Patients with non-valvular AF in the UC Health system were identified using appropriate ICD-10 codes for any hospitalization or visit at an ambulatory center over the one-year period from January through December 2016. Data were extracted from the electronic health record for individual patients, and patient-level analyses were performed by the decision analytic model to compare treatment strategies, including the LAAC option, in terms of quality-adjusted life years (QALYs). Our analysis focused on patients with a CHA2DS2VASc score = 3, consistent with current CMS approval of the LAAC device. Results: There were 3,486 with a CHA2DS2VASc = 3. The most frequent optimal strategy was a DOAC, for 3,097 patients (88.8%). The LAAC was the second-best strategy, for 312 patients (9%). No prophylaxis was optimal for 71 patients (2%), aspirin for 5 patients (0.1%), and warfarin for 1 patient. For those patients with chronic kidney disease stage 4 or higher, the LAAC was the optimal strategy for 93.6% (292 patients) of these patients. Conclusions: LAAC was not the optimal strategy for most UC Health patients with AF, but rather a DOAC was. The LAAC was, however, the optimal strategy for most patients with chronic kidney disease stage 4 or higher. Our analysis suggests that this subpopulation in particular could benefit from a LAAC device. Perhaps future clinical studies involving a LAAC device could focus on this patient sub-population specifically.
Erin Haynes, Dr.P.H. (Committee Chair)
Mark Eckman, M.D. (Committee Member)
Roman Jandarov (Committee Member)
17 p.

Recommended Citations

Citations

  • Rose, A. (2018). A Decision Analysis of Left Atrial Appendage Closure as an Alternative to Long-Term Anticoagulation in a Health System's Patients with Atrial Fibrillation [Master's thesis, University of Cincinnati]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1542723664655377

    APA Style (7th edition)

  • Rose, Adam. A Decision Analysis of Left Atrial Appendage Closure as an Alternative to Long-Term Anticoagulation in a Health System's Patients with Atrial Fibrillation. 2018. University of Cincinnati, Master's thesis. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=ucin1542723664655377.

    MLA Style (8th edition)

  • Rose, Adam. "A Decision Analysis of Left Atrial Appendage Closure as an Alternative to Long-Term Anticoagulation in a Health System's Patients with Atrial Fibrillation." Master's thesis, University of Cincinnati, 2018. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1542723664655377

    Chicago Manual of Style (17th edition)