Warfarin and Antiplatelet Therapy Versus Warfarin Alone for Treating Patients With Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement

Altisent, Omar Abdul‐Jawad; Durand, Éric; Muñoz-García, Antonio J.; Nombela‐Franco, Luis; Cheema, Asim N.; Kefer, Joëlle; Gutiérrez‐Ibañes, Enrique; Benítez, Luis; Amat‐Santos, Ignacio J.; Serra, Violeta; Eltchaninoff, Hélène; Alnasser, Sami; Elı́zaga, Jaime; Dager, Antonio; Blanco, Bruno García del; Ortas-Nadal, Maria del Rosario; Marsal, Josep Ramón; Campelo‐Parada, Francisco; Regueiro, Ander; Trigo, María Del; Dumont, Éric; Puri, Rishi; Rodés‐Cabau, Josep

doi:10.1016/j.jcin.2016.06.025

Cited by 116 publications

(45 citation statements)

References 21 publications

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“…A decision was made to switch from dual antiplatelet therapy (DAPT) without a loading dose prior to TAVR to single antiplatelet therapy (SAPT) with a P2Y 12 loading dose prior to TAVR for patients who do not require chronic systemic anticoagulation. This change in protocol was based on data from small trials and meta‐analyses that demonstrated similar efficacy and improved safety profile with SAPT versus DAPT . Patients requiring anticoagulation were treated with anticoagulation alone (no antiplatelet drugs) before or after TAVR.…”

Section: Methodsmentioning

confidence: 99%

“…Patients requiring anticoagulation were treated with anticoagulation alone (no antiplatelet drugs) before or after TAVR. Anticoagulation was held 2 days prior to the procedure and restarted on the day after the procedure without bridging therapy . Chart review of all patients who underwent TAVR during the 9‐month study period identified 266 patients.…”

Section: Methodsmentioning

confidence: 99%

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Preprocedural P2Y₁₂ inhibition and decrease in platelet count following transcatheter aortic valve replacement

Ibrahim

Vapheas

Shah

et al. 2019

Cathet Cardio Intervent

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Background Thrombocytopenia after transcatheter aortic valve replacement (TAVR) is associated with adverse clinical outcomes. Whether preprocedural P2Y12 inhibition prevents postprocedural thrombocytopenia is uncertain. Methods This retrospective analysis identified consecutive patients (n = 266) undergoing TAVR between November 2016 and July 2017. Preprocedure clopidogrel load ≥300 mg or maintenance P2Y12 inhibitor therapy defined preprocedural P2Y12 inhibition. Patients who did not consent for the registry (n = 8), with baseline severe thrombocytopenia (<90 × 103 platelets/μL; n = 14), or without baseline platelet count (n = 4) were excluded. The primary outcome was proportion of patients who developed >20% decrease in platelet count from baseline to day 1 post‐TAVR. Results Patients with (n = 134) versus without (n = 106) preprocedural P2Y12 inhibition had no differences in platelet count at baseline. Patients with preprocedural P2Y12 inhibition had a significantly lower proportion of the primary outcome (34.3% vs. 57.5%, p = .001) and a lower absolute decrease in platelet count (32.8 × 103 vs. 45.8 × 103 platelet/μL, p = .01). Of patients without baseline thrombocytopenia (n = 198), a numerically lower rate of patients with versus without preprocedural P2Y12 inhibition developed thrombocytopenia on day 1 post‐TAVR (25.5% vs. 36.4%, p = .1). Conclusion Patients who received preprocedural P2Y12 inhibition prior to TAVR were less likely to demonstrate a decrease in platelet count after TAVR. Prospective studies to further understand the clinical implication of these findings are warranted.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Preprocedural P2Y₁₂ inhibition and decrease in platelet count following transcatheter aortic valve replacement

Ibrahim

Vapheas

Shah

et al. 2019

Cathet Cardio Intervent

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“…The addition of APT to VKA in patients with TAVI is associated with similar stroke or death rates, but an increased rate of major and/or life-threatening bleeding 29. In another study, VKA monotherapy resulted in a lower risk of the combined endpoint of post-procedural mortality, stroke, embolism and major bleeding 30…”

Section: Oral Anticoagulationmentioning

confidence: 99%

Antithrombotic therapy in patients undergoing transcatheter aortic valve implantation

Nijenhuis

Brouwer

Søndergaard

et al. 2019

Heart

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This review provides a comprehensive overview of the available data on antithrombotic therapy after transcatheter aortic valve implantation (TAVI). In the absence of large randomised clinical trials, clinical practice is leaning towards evidence reported in other populations. Due to the greater risk of major bleeding associated with oral anticoagulation using a vitamin-K antagonist (VKA), antiplatelet therapy (APT) may be considered as the first-line treatment of patients undergoing TAVI. Overall, single rather than dual APT is preferred. However, dual APT should be considered in patients with a recent acute coronary syndrome (ie, within 6 months), complex coronary stenting, large aortic arch atheromas or previous non-cardioembolic stroke. Monotherapy with VKA should be considered if concomitant atrial fibrillation or any other indication for long-term oral anticoagulation is present. APT on top of VKA seems only reasonable in patients with recent acute coronary syndrome, extensive or recent coronary stenting or large aortic arch atheromas. A direct-acting oral anticoagulant may be considered if oral anticoagulation is indicated in the absence of contraindications. Initiation of VKA is indicated in clinical valve thrombosis, for example, with high transvalvular gradient, whereas the role of VKA in the case of subclinical leaflet thrombosis is currently uncertain.

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“…Patients with valve thrombosis or atrial fibrillation may need anticoagulation with VKA therapy. Abdul-Jawad et al[39] revealed that for patients with VKA therapy, concomitant antiplatelet therapy had no significant difference on stroke or death, while significantly increasing the incidence of major and lethal bleeding. However, the clinical outcomes remain unclear.…”

Section: Discussionmentioning

confidence: 99%

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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Warfarin and Antiplatelet Therapy Versus Warfarin Alone for Treating Patients With Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement

Abstract: In TAVR recipients prescribed VKA therapy for AF, concomitant antiplatelet therapy use appears not to reduce the incidence of stroke, major adverse cardiovascular events, or death, while increasing the risk of major or life-threatening bleeding.

Cited by 116 publications

References 21 publications

Preprocedural P2Y₁₂ inhibition and decrease in platelet count following transcatheter aortic valve replacement

Preprocedural P2Y₁₂ inhibition and decrease in platelet count following transcatheter aortic valve replacement

Antithrombotic therapy in patients undergoing transcatheter aortic valve implantation

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

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Warfarin and Antiplatelet Therapy Versus Warfarin Alone for Treating Patients With Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement

Abstract: In TAVR recipients prescribed VKA therapy for AF, concomitant antiplatelet therapy use appears not to reduce the incidence of stroke, major adverse cardiovascular events, or death, while increasing the risk of major or life-threatening bleeding.

Cited by 116 publications

References 21 publications

Preprocedural P2Y12 inhibition and decrease in platelet count following transcatheter aortic valve replacement

Preprocedural P2Y12 inhibition and decrease in platelet count following transcatheter aortic valve replacement

Antithrombotic therapy in patients undergoing transcatheter aortic valve implantation

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

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Product

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Preprocedural P2Y₁₂ inhibition and decrease in platelet count following transcatheter aortic valve replacement

Preprocedural P2Y₁₂ inhibition and decrease in platelet count following transcatheter aortic valve replacement