Antithrombotic Therapy for AF Patients Undergoing TAVR

Study Questions:

What are the risks of ischemic events and bleeding episodes associated with warfarin plus antiplatelet therapy versus warfarin alone for patients with atrial fibrillation (AF) undergoing transcatheter aortic valve replacement (TAVR)?

Methods:

Using a multicenter registry of TAVR patients, 621 patients with concomitant AF were identified. Patients were divided into monotherapy (warfarin only) or multiple antithrombotic therapy (MAT) cohorts. Rates of stroke, major adverse cardiovascular events (stroke, myocardial infarction, or cardiovascular death), major or life-threatening bleeding, and death were assessed using a Cox multivariable survival model.

Results:

During a median follow-up of 12 months (interquartile range [IQR], 3-31 months), there was no difference between the monotherapy and MAT cohorts in the rate of stroke (5% vs. 5.2%; adjusted hazard ratio [aHR], 1.25; 95% confidence interval [CI], 0.45-3.48), major adverse cardiovascular events (13.9% vs. 16.3%; aHR, 1.33; 95% CI, 0.75-2.36), and death (22.8% vs. 19.2%; aHR, 0.93; 95% CI, 0.58-1.50). There was a higher risk of major or life-threatening bleeding in the MAT versus monotherapy cohort (24.4% vs. 14.9%; aHR, 1.85; 95% CI, 1.05-3.28).

Conclusions:

The authors concluded that TAVR patients with concomitant AF do not appear to benefit from MAT therapy as compared to warfarin monotherapy.

Perspective:

This study highlights a common clinical conundrum: how best to combine antithrombotic therapy for patients with multiple indications. As has been described in a number of other clinical situations, this study suggests that more is not always better. In fact, use of warfarin monotherapy may offer similar protection against ischemic events while reducing the risk of bleeding associated with multiple antithrombotic therapy regimens. While warfarin monotherapy reduced the overall risk of significant bleeding, the absolute risk remains elevated. The patient and providers should make all reasonable efforts to reduce bleeding risk whenever possible.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Fibrinolytic Agents, Heart Valve Diseases, Hemorrhage, Myocardial Infarction, Platelet Aggregation Inhibitors, Risk Management, Stroke, Secondary Prevention, Transcatheter Aortic Valve Replacement, Warfarin


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