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

Abstract

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.

Thromboembolic and Bleeding Complications in Transcatheter Aortic Valve Implantation: Insights on Mechanisms, Prophylaxis and Therapy

“…A pattern, however, was noted in favour of fewer life-threatening and major bleeds in the ASA (aspirin) group compared with DAPT, questioning the value of clopidogrel in this context. Two recent meta-analyses conducted by Hu et al and Ahmad et al reached similar conclusions, suggesting that DAPT, when compared with SAPT following TAVI, displays non-superiority in reducing thrombotic events but involves added risk of major and life-threatening bleeds [62,63]. However, these findings are diluted somewhat by the fact that the analyses are based on small studies, many of which are non-randomised, with short follow-up periods.…”

Incidence, Current Guidelines and Management of Gastrointestinal Bleeding after Transcatheter Aortic Valve Replacement: A Systematic Review

“…Here we have also included meta-analyses of the RCTs that are relevant to the issue (Table 2 ), with Osman and colleagues conducting the most recent one, which showed a significant reduction in clinically significant bleeding (CSB) in the group on aspirin monotherapy as compared with DAPT (HR 0.49, 95% CI 0.32-0.75, p= 0.001, NNT=19) [ 23 - 30 ]. They did not find any difference between aspirin monotherapy and DAPT groups in terms of all-cause mortality (HR 1.00, 95% CI 0.62-1.62, p= 1.00) [ 31 ].…”

Antithrombotic Therapy After Transcatheter Aortic Valve Implantation

“…41 Overall, cumulative data from observational and small randomised investigations considered together do not support current common practice of DAPT after TAVI, as it has not been proven superior in reducing thromboembolic events compared with SAPT with aspirin, which could be a safer and similarly effective option. 42 Some on-going trials that are mentioned below are presently testing this hypothesis and will provide important insights on the subject.…”