In patients with prior atrial fibrillation undergoing transcatheter aortic valve replacement, 6 months of uninterrupted antiplatelet therapy, with or without concomitant oral anticoagulation, was associated with a reduced risk of stroke at 2 years, whereas oral anticoagulation alone did not reduce risk in this population.
According to a study published in JACC: Cardiovascular Interventions, in a cohort of patients with prior AF and aortic stenosis who underwent TAVR, those who received anticoagulant therapy had a similar rate of stroke (6.6% vs. 5.6%; P = .53) and the combined outcome of death or stroke (29.7% vs. 31.8%; P = .33) at 2 years, compared with those who did not receive oral anticoagulation.
Patients who received oral anticoagulation with antiplatelet therapy had a reduced rate of stroke (5.4% vs. 11.1%; P = .03) and death or stroke (29.7% vs. 40.1%; P = .01) compared with those who received no oral anticoagulation or antiplatelet therapy. After adjustment, the researchers reported that oral anticoagulation with antiplatelet therapy and antiplatelet therapy alone reduced rates of stroke at 2 years compared with no oral anticoagulation or antiplatelet therapy (HR for anticoagulation and antiplatelet = 0.43; 95% CI, 0.22-0.85; P = .015; HR for antiplatelet only = 0.32; 95% CI, 0.16-0.65; P = .002), while oral anticoagulation alone did not result in reduced stroke.
“Our findings suggest that, alone, oral anticoagulation may not be sufficient,” Ioanna Kosmidou, MD, PhD, assistant professor of medicine at NewYork-Presbyterian Hospital/Columbia University Medical Center, said in an interview. “In fact, we showed that these patients probably require concomitant antiplatelet therapy for at least several months after they undergo TAVR, likely because the risk for stroke in that particular patient population is not only related to cardioembolic phenomena from AF, but also other factors that we need to be considering. I believe these findings will have a significant impact in terms of the choice of an antithrombotic regimen for this particular patient population.”
This retrospective study used data from the PARTNER II trial and associated registries, including 1,621 patients with prior AF and a CHA2DS2-VASc score of 2 higher to analyze the impact of antithrombotic treatment patterns on clinical outcomes including death or stroke, stroke or transient ischemia attack, bleeding, aortic valve reintervention and prosthetic valve dysfunction.
During the 5-year enrollment period for the PARTNER II trial, 57.6% of patients with AF were discharged on oral anticoagulant therapy following TAVR. In total, uninterrupted antiplatelet therapy for a minimum of 6 months, or until a CV endpoint occurred, was used in 58.3% of patients on oral anticoagulation and 77.5% of those not on oral anticoagulation, according to the results.
“Our findings suggest that, in patients with AF and an absolute indication for oral anticoagulation, antiplatelet therapy according to current guidelines on post-TAVR therapy should not be omitted. However, randomized studies are needed to determine the optimal antithrombotic regimen and duration of therapy in patients with AF undergoing TAVR,” Kosmidou said. – by Scott Buzby
For more information:
Ioanna Kosmidou, MD, PhD , can be reached at Columbia University Medical Center, Herbert Irving Pavillion-6, New York, NY 10032; email: firstname.lastname@example.org; Twitter: @IKosmidou.
Disclosures: Kosmidou reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.