Stroke after TAVR in AFib patients: Key risk factors cardiologists should know
How can cardiologists limit ischemic strokes in patients with atrial fibrillation (AFib) following a successful transcatheter aortic valve replacement (TAVR)? Do oral anticoagulation (OAC) strategies make a difference?
A team of specialists hoped to answer those very questions, reviewing global data from nearly 1,400 TAVR patients and sharing their findings in The American Journal of Cardiology.[1]
“For patients with an incident or prevalent AFib after TAVR, continued postprocedural pharmacotherapy with an OAC is recommended as a treatment to improve clinical outcomes,” wrote first author Christian Hengstenberg, MD, a cardiologist with Vienna General Hospital, and colleagues. “More data are needed to elucidate the risk of ischemic stroke in these patients.”
The group evaluated data from ENVISAGE-TAVI AF, a global randomized trial focused on ischemic stroke in patients with incident or prevalent AFib who undergo a successful TAVR. The goal of the trial was to examine differences in patients treated with edoxaban or a vitamin K antagonist (VKA).
Data from ENVISAGE-TAVI AF were originally published in The New England Journal of Medicine in 2021.[2] For this updated analysis, researchers only tracked findings from patients who received treatment as opposed to all patients originally selected to participate.
Overall, the Hengstenberg et al. tracked data from 1,377 TAVR patients. A total of 3% experienced an ischemic stroke following treatment. There were no significant differences in demographic or clinical characteristics between patients who did and did not experience an ischemic stroke. Mean CHA2DS2-VASc and Society of Thoracic Surgeons scores were also comparable.
The overall ischemic stroke rates were 3.5% for patients given a 30-mg dose of edoxaban, 2.1% for patients given a 60-mg dose of edoxaban and 3.6% for patients given a VKA.
Among edoxaban patients, ischemic stroke was seen at a rate of 2 per 100 person-years. For the VKA arm, the rate was 2.7 per 100 person-years. A majority of ischemic strokes occurred within the first 180 days following treatment. At least 20% of ischemic strokes occurred within the first 30 days in both groups—21.1% for the edoxaban arm and 22.7% for the VKA arm.
“Early events are believed to be directly related to the procedure, whereas delayed events are believed to be related to either the TAVR procedure or patient-specific factors,” the authors wrote. “Late-phase events are mostly associated with patient- and disease-related factors, including older age. Thus, in the present study, the occurrence of ischemic stroke more than 30 days after TAVR might be primarily representative of a natural development of cardiovascular disease triggered by the progress of age and cardiovascular risk factors.”
One key takeaway from the team’s research was the fact that both a history of systemic embolic events (SEEs) and a history of VKA use prior to TAVR were both independently associated with an increased risk of ischemic stroke.
“Identifying ischemic stroke risk factors in patients with AF after TAVI is important for making informed treatment decisions and optimizing clinical outcomes,” the authors wrote. “This analysis identified a history of SEE and the pre-TAVR use of VKAs as risk factors independently associated with ischemic stroke. Pre-TAVR use of VKAs as a predictor may be the result of differences in patient characteristics that lead to the prescription of VKAs versus non–VKA OACs. Additional factors contributing to this observation may include the deteriorating health or longer duration of AFib for patients receiving OAC than for those not receiving OAC before TAVR.”
In addition, the team noted, the OAC strategy of choice did not appear to influence how patients recovered if they did experience an ischemic stroke—event severity and outcome were similar for the two groups.
Hengstenberg and colleagues concluded by highlighting the low stroke rates for both OAC treatment strategies. In addition, they wrote, determining which TAVR patients with AFib have a prior history of SEEs or VKA use may help cardiologists put together an optimal treatment plan following the procedure.
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Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.