Antiplatelet Therapy After TAVI

Jul 28, 2015
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Authors:
Hassell ME, Hildick-Smith D, Durand E, et al.
Citation:
Antiplatelet Therapy Following Transcatheter Aortic Valve Implantation. Heart 2015;101:1118-1125.
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What is the efficacy and safety of aspirin-only (ASA) versus dual antiplatelet therapy (DAPT) following transcatheter aortic valve implantation (TAVI)?

Methods:

The investigators performed a systematic review and pooled analysis of individual patient data from 672 participants comparing single versus DAPT following TAVI. The primary endpoint was defined as the composite of net adverse clinical and cerebral events (NACE) at 1 month, including all-cause mortality, acute coronary syndrome (ACS), stroke, and life-threatening and major bleeding. For the nonrandomized studies, the authors applied propensity-score matching to account for differences in baseline characteristics between patients treated with ASA or DAPT. In each observational study separately, a multivariable logistical regression model was used to estimate propensity scores, with the two groups (i.e., DAPT vs. ASA) as dependent variables and potential confounders as covariates.

Results:

At 30 days, a NACE rate of 13% was observed in the ASA-only and in 15% of the DAPT group (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.48-1.43; p = 0.50). A tendency toward less life-threatening and major bleeding was observed in patients treated with ASA (OR, 0.56; 95% CI, 0.28-1.11; p = 0.09). Also, ASA was not associated with an increased all-cause mortality (OR, 0.91; 95% CI, 0.36-2.27; p = 0.83), ACS (OR, 0.5; 95% CI, 0.05-5.51; p = 0.57), or stroke (OR, 1.21; 95% CI, 0.36-4.03; p = 0.75).

Conclusions:

The authors concluded that no difference in the 30-day NACE rate was observed between ASA-only or DAPT following TAVI.

Perspective:

This collaborative patient-level pooled analysis of all available studies comparing two antiplatelet regimes found no difference in 30-day NACE between ASA-only or DAPT following TAVI. Moreover, a trend toward less life-threatening and major bleeding was observed in the ASA treatment group. Based on the results of this study, the additive value of clopidogrel on top of ASA is questionable, but warrants further investigation with an adequately powered randomized trial with both ischemic and bleeding clinical endpoints to assess the efficacy and safety of ASA-only versus DAPT.

Keywords: Acute Coronary Syndrome, Aspirin, Heart Valve Diseases, Hemorrhage, Platelet Aggregation Inhibitors, Stroke, Ticlopidine, Transcatheter Aortic Valve Replacement


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