Dual Versus Single Antiplatelet Therapy in Patients Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-analysis

Aryal, Madan Raj; Karmacharya, Paras; Pandit, Anil; Hakim, Fayaz A.; Pathak, Ranjan; Mainali, Naba Raj; Ukaigwe, Anene; Mahmood, Maryam; Badal, Madan; Fortuin, F. David

doi:10.1016/j.hlc.2014.07.058

Cited by 33 publications

(14 citation statements)

References 22 publications

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“…27 The meta-analysis on the use of single versus dual antiplatelet therapies after TAVR suggested increased bleeding at 30 days when dual antiplatelet therapies were used. 28 Moreover, a small study suggested the incidence of valve thrombosis in post-TAVR patients found via autopsy. 29 Most investigators think that transcatheter valves are comparable favorably with surgically implanted valve and that potential mechanisms of thrombosis should be similar.…”

Section: Discussionmentioning

confidence: 99%

Safety and Use of Anticoagulation After Aortic Valve Replacement With Bioprostheses

Riaz

Al-Ansari

Khan

et al. 2016

Circ: Cardiovascular Quality and Outcomes

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Background The American College of Cardiology guidelines recommend 3 months of anticoagulation after replacement of the aortic valve with a bioprosthesis. However, there remains great variability in the current clinical practice and conflicting results from clinical studies. To assist clinical decision making, we pooled the existing evidence to assess whether anticoagulation in the setting of a new bioprosthesis was associated with improved outcomes or greater risk of bleeding. Methods and Results We searched the PubMed database from the inception of these databases until April 2015 to identify original studies (observational studies or clinical trials) that assessed anticoagulation with warfarin in comparison with either aspirin or no antiplatelet or anticoagulant therapy. We included the studies if their outcomes included thromboembolism or stroke/transient ischemic attacks and bleeding events. Quality assessment was performed in accordance with the Newland Ottawa Scale, and random effects analysis was used to pool the data from the available studies. I2 testing was done to assess the heterogeneity of the included studies. After screening through 170 articles, a total of 13 studies (cases=6431; controls=18210) were included in the final analyses. The use of warfarin was associated with a significantly increased risk of overall bleeding (odds ratio, 1.96; 95% confidence interval, 1.25–3.08; P<0.0001) or bleeding risk at 3 months (odds ratio, 1.92; 95% confidence interval, 1.10–3.34; P<0.0001) compared with aspirin or placebo. With regard to composite primary outcome variables (risk of venous thromboembolism, stroke, or transient ischemic attack) at 3 months, no significant difference was seen with warfarin (odds ratio, 1.13; 95% confidence interval, 0.82–1.56; P=0.67). Moreover, anticoagulation was also not shown to improve outcomes at time interval >3 months (odds ratio, 1.12; 95% confidence interval, 0.80–1.58; P=0.79). Conclusions Contrary to the current guidelines, a meta-analysis of previous studies suggests that anticoagulation in the setting of an aortic bioprosthesis significantly increases bleeding risk without a favorable effect on thromboembolic events. Larger, randomized controlled studies should be performed to further guide this clinical practice.

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Section: Discussionmentioning

confidence: 99%

Safety and Use of Anticoagulation After Aortic Valve Replacement With Bioprostheses

Riaz

Al-Ansari

Khan

et al. 2016

Circ: Cardiovascular Quality and Outcomes

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“…In comparison with the studies by Gandhi et al [34] and Aryal et al [35], we found some further information, as follows: (1) no discrepancies in the incidence of 30-day minor stroke, TIA, minor bleeding, major vascular complications, 6-month and 1-year clinical outcomes were revealed; (2) the study type, valve, and use of a clopidogrel preload had little effect on 30-day stroke (major, minor, and TIA), all-cause mortality, and major and lethal bleeding, but did impact on 30-day MI.…”

Section: Discussionmentioning

confidence: 48%

Single versus Dual Antiplatelet Therapy after Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

Yang

Wang

et al. 2018

Cardiology

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Objectives: Although dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is currently recommended in patients after transcatheter aortic valve implantation (TAVI), this practice is not supported by sufficient evidence. This study was performed to compare DAPT to single antiplatelet therapy (SAPT). Methods: An electronic search was completed of PubMed, Embase, Ovid Medline, Web of Science, and Cochrane Central Register of Controlled Trials. Studies comparing DAPT versus SAPT in patients undergoing TAVI were included. Results: Seven studies incorporating 1,445 patients were eligible for the present meta-analysis. There were no significant differences on 30-day all-cause mortality (OR 1.19, 95% CI 0.63–2.25, p = 0.593), 6-month all-cause mortality (OR 1.11, 95% CI 0.49–2.53, p = 0.796), or 1-year all-cause mortality (OR 1.19, 95% CI 0.63- 2.25, p = 0.593). DAPT was associated with an increased risk for 30-day (OR 2.91, 95% CI 1.85–4.58, p < 0.01), 6-month (OR 2.54, 95% CI 1.26–5.10, p < 0.001), and 1-year major and lethal bleeding (OR 2.65, 95% CI 1.04–6.77, p = 0.041) based on 896, 337, and 583 patients, respectively, compared to SAPT. Conclusion: Compared to SAPT, DAPT was not shown to be superior in reducing thrombotic events, but presented an increased risk of major/life-threatening bleeding. More randomized controlled trials are needed to provide further evidence.

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“…A trial evaluating 171 patients undergoing transfemoral (87%), trans‐subclavian (7%), and transapical (3%) implantation of the CoreValve demonstrated significantly higher overall vascular event rates with DAPT versus ASA monotherapy, although the effect was mainly driven by bleeding complications . Similarly, a meta‐analysis found no difference in stroke or myocardial infarction events 30 days post‐TAVR in patients who received DAPT compared with SAPT, but an increase in bleeding was observed with DAPT . Results from the first prospective, randomized trial evaluating outcomes at 3 months following TAVR in patients receiving ASA compared with DAPT revealed no difference in ischemic outcomes but an increase in 90‐day bleeding rates .…”

Section: Pharmacologic Considerations For Patients Undergoing Tavrmentioning

confidence: 98%

Medication Management of Patients Undergoing Transcatheter Aortic Valve Replacement

2017

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Aortic stenosis (AS) is the most common form of valvular heart disease. A detailed diagnostic workup is necessary to promptly stage and classify disease severity to determine optimal management. Medical therapy and valvuloplasty are options that fail to delay or reverse disease progression. Surgical aortic valve replacement (SAVR) is curative but has significant limitations for some patient populations. A newer option, transcatheter aortic valve replacement (TAVR), has become more widely available to patients with intermediate‐ or high‐operative risk. Periprocedural medication management is imperative for successful valve implantation and to minimize adverse events. Stroke remains one of the most common complications of TAVR and is associated with increased mortality. Thus, intra‐ and postprocedural antithrombotic therapy is required, although the regimen that best minimizes thromboembolic events and bleeding complications has yet to be defined. Patients undergoing TAVR with comorbid conditions requiring oral anticoagulation or individuals who develop subvalvular thromboses pose unique challenges. Antiplatelet and anticoagulant therapy should be carefully balanced. This article summarizes key literature supporting the pharmacologic management of patients receiving TAVR.

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Dual Versus Single Antiplatelet Therapy in Patients Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-analysis

Cited by 33 publications

References 22 publications

Safety and Use of Anticoagulation After Aortic Valve Replacement With Bioprostheses

Safety and Use of Anticoagulation After Aortic Valve Replacement With Bioprostheses

Single versus Dual Antiplatelet Therapy after Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

Medication Management of Patients Undergoing Transcatheter Aortic Valve Replacement

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