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Direct Oral Anticoagulants vs. Vitamin K Antagonists in AF After TAVR
Quick Takes
- Patients with AF undergoing TAVR had lower rates of death when treated with DOAC therapy versus VKA.
- Bleeding rates were similar between patients with AF treated with DOAC and VKA groups following TAVR.
Study Questions:
What is the long-term all-cause mortality in patients with atrial fibrillation (AF) and transcatheter aortic valve replacement (TAVR) treated with direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs)?
Methods:
The authors used the OCEAN (Optimized Transcatheter Valvular Intervention) prospective, multicenter (n = 14), observational cohort registry to examine 2,588 patients with TAVR between October 2013 and May 2017. They compared outcomes among the 403 (15.6%) patients with concomitant AF who were treated with either a DOAC (227, 56.3%) or VKA (176, 43.7%) following hospital discharge using Cox regression and an inverse probability treatment weight propensity scoring approach. The primary outcome was all-cause mortality.
Results:
The cohort consisted of 134 (33.3%) men with a mean age of 84.4 ± 4.7 years and a mean CHA2DS2-VASc score of 5.1 ± 1.1. Median follow-up was 568 days (interquartile range, 367-819). All-cause mortality was less common in patients treated with DOACs versus VKAs when analyzed both with Cox regression (10.3% vs. 23.3%; hazard ratio [HR], 0.391; 95% confidence interval [CI], 0.204-0.749) and probability score weighting (10.2% vs. 20.6%; HR, 0.531; 95% CI, 0.249-0.961). The rate of any bleeding was comparable between the two treatment groups (9.7% for VKA and 5.3% for DOAC at 720 days; HR, 0.573; 95% CI, 0.273-1.201).
Conclusions:
The authors concluded that DOAC use among patients with AF undergoing TAVR may be associated with lower long-term all-cause mortality.
Perspective:
Despite all of the limitations from a retrospective study, this analysis provides further support that use of DOACs are safe and effective for patients following TAVR if they have a clear indication (e.g., AF). This finding is important given the results of the GALILEO study (Dangas GD, et al., N Engl J Med 2020;383:120-9), which reported higher rates of death in patients treated with prophylactic doses of rivaroxaban following TAVR. Importantly, patients in the GALILEO study did not have another indication for anticoagulation. Therefore, if patients have an indication for anticoagulation (e.g., stroke prevention in AF), DOAC therapy is reasonable even following TAVR as long as other contraindications are not present (e.g., severe drug-drug interaction, anti-phospholipid antibody syndrome, mechanical valve).
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias
Keywords: Anti-Arrhythmia Agents, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Surgical Procedures, Geriatrics, Hemorrhage, Patient Discharge, Stroke, Transcatheter Aortic Valve Replacement, Vascular Diseases, Vitamin K
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