Oral Anticoagulant Type and Outcome After TAVR

Study Questions:

What is the impact of oral anticoagulation (OAC) type on clinical outcomes 1 year after transcatheter aortic valve replacement (TAVR)?

Methods:

This study enrolled 962 consecutive patients who underwent TAVR at four centers in Europe and were discharged on either a nonvitamin K antagonist OAC (NOAC) or vitamin K antagonist (VKA). Using propensity scores with inverse probability weighting, they compared the rates of all-cause mortality, myocardial infarction (MI), and cerebrovascular events within 1 year of TAVR placement. They also assessed for bleeding events.

Results:

Among the 326 patients treated with NOAC and 636 patients treated with VKA, the mean age was 81.3 ± 6.3 years, mean Society of Thoracic Surgeons score was 4.5% (interquartile range, 3.0-7.3%), and 52.5% were women. Balloon-expandable TAVR was used in 62.7% of cases. The combined incidence of all-cause mortality, MI, and cerebrovascular event occurred in 21.2% of NOAC-treated patients and 15.0% of VKA-treated patients (adjusted hazard ratio [aHR], 1.44; 95% confidence interval [CI], 1.00-2.07). The 1-year incidence of bleeding was 33.9% versus 34.1% in the NOAC- and VKA-treated patients (aHR, 0.97; 95% CI, 0.74-1.26). The 1-year incidence of all-cause mortality was 16.5% versus 12.2% in the NOAC- and VKA-treated patients (aHR, 1.36; 95% CI, 0.90-2.06).

Conclusions:

The authors concluded that chronic use of NOAC and VKA among patients undergoing TAVR showed comparable bleeding risk. They also noted that the trend towards higher ischemic event rates with NOAC versus VKA require further exploration in large, randomized trials.

Perspective:

Up to 50% of patients undergoing TAVR for aortic stenosis have an indication for chronic OAC use (e.g., atrial fibrillation). This study provides evidence that there is little difference in bleeding risk between use of NOAC and VKA medications. However, it raises the possibility that NOAC use in the setting of TAVR might be associated with more ischemic events. Based on the cumulative incidence curves, there is some suggestion that the difference in thromboembolic risk may increase over time and that studies with longer follow-up are needed. Many patients and clinicians favor use of NOACs following TAVR given their relative ease of use and overall lower risk of intracranial hemorrhage. However, if the increased thromboembolic risk identified in this retrospective analysis were confirmed in prospective studies, that would change clinical practice. Current American College of Cardiology/American Heart Association (ACC/AHA) valvular heart disease guidelines do not stipulate if VKAs or NOACs are preferred in patients with TAVR who have another indication for OAC use. And the ACC/AHA atrial fibrillation guidelines only indicate that mechanical heart valves are a contraindication to NOAC use. Until prospective data are available, clinicians should alert their patients to the possibility of increased thromboembolic risk if NOAC use is selected over VKA following TAVR.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Anticoagulants, Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Risk, Thromboembolism, Thrombolytic Therapy, Transcatheter Aortic Valve Replacement, Vascular Diseases, Vitamin K


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