Patients prescribed direct oral anticoagulants (DOACs) after undergoing transcatheter aortic valve replacement (TAVR) may face a higher risk of death than patients prescribed antiplatelet therapy, according to a new meta-analysis published in Circulation: Cardiovascular Interventions.[1]
“Societal guidelines recommend a short regimen of antiplatelet therapy (either aspirin alone or dual antiplatelet therapy) after TAVR in patients without an indication for chronic oral anticoagulation (OAC),” wrote lead author Ayman Elbadawi, MD, a cardiologist with the University of Texas Southwestern Medical Center, and colleagues. “Recent randomized controlled trials (RCTs) demonstrated that OACs are associated with a trend toward lower incidence of leaflet thrombosis, however; this did not translate into lower rates of ischemic events. In that context, we aimed to conduct a meta-analysis of RCTs to investigate the efficacy and safety of OAC after TAVR among patients without an indication for chronic OAC therapy.”
Elbadawi et al. focused on data from nearly 3,000 patients who participated in one of three RCTs. The weighted follow-up period was 15 months, and none of the patients had an indication for chronic OAC therapy.
DOACs included in the three RCTs were rivaroxaban, apixaban and edoxaban. Antiplatelet therapies included in the three RCTs were dual antiplatelet therapy (DAPT) with aspirin and clopidogrel or single antiplatelet therapy (SAPT).
Overall, the team found, DOACs were linked to a higher all-cause mortality rate (6.7% vs. 4%) and noncardiac mortality rate (2.9% vs. 1.2%) than DAPT/SAPT. DOACs were also associated with higher cardiac mortality (3.8% vs. 2.7%) and major/life-threatening bleeding event (6.4% vs. 5%) rates, though those differences were not quite as significant.
When looking at bleeding events, acute cerebrovascular accidents and systemic thromboembolic events, the authors saw “no significant differences” between the two treatment options.
In addition, DOACs were linked to lower incidence of hypo-attenuated leaflet thickening (9.1% vs. 18.3%) and restricted leaflet motion (1.7% vs. 8.6%).
“Collectively, these findings support the notion that hypo-attenuated leaflet thickening and restricted leaflet motion may not carry significant clinical implications in short-term outcomes after TAVR but rather represent subclinical advanced-imaging phenomena,” the authors wrote.
The researchers concluded their analysis by highlighting the need for more research on this topic.
“It would be of interest to identify subgroups of patients with a favorable risk/benefit profile with DOACs, who could possibly attain the prevention of leaflet thrombo-sis without excess bleeding harm,” they wrote.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.