Meta-Analysis Comparing Dual Antiplatelet Therapy Versus Single Antiplatelet Therapy Following Transcatheter Aortic Valve Implantation

https://doi.org/10.1016/j.amjcard.2018.06.048Get rights and content

The present American College of Cardiology/American Heart Association guidelines (Grade IIb, level of evidence C) recommend dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 6 months followed by lifelong aspirin after transcathter aortic valve implantation (TAVI). However, studies that have compared DAPT to single antiplatelet therapy (SAPT) after TAVI have questioned this recommendation as DAPT has been associated with more bleeding events compared with SAPT. We performed a meta-analysis of all the trials that compared DAPT to SAPT in patients who underwent TAVI. Three randomized trials and 4 nonrandomized studies were included. The primary endpoint was the rate of ischemic stroke. Secondary end points were the rates of myocardial infarction, life threatening bleeding (LTB), significant bleeding (LTB and major bleeding), and death. The Mantel-Haenszel random effects model was used to calculate the combined odds ratios (OR) and 95% confidence intervals (CI) for outcomes at 30days and up to 6 to 12months follow-up. The LTB (OR 2.73, 95% CI 1.31 to 5.69, p = 0.007) and significant bleeding rates (OR 2.76, 95% CI 1.57 to 4.85, p = 0.0004) were significantly higher in DAPT arm at 30days. Significant bleeding (OR 2.24, 95% CI 1.33 to 3.79, p = 0.002) was still significantly higher in the DAPT arm but there was only a nonsignificant trend toward higher LTB (OR 1.93 95% CI 0.61 to 6.03, p = 0.26) at 6 to 12 month follow up. There was no difference in mortality, ischemic stroke and myocardial infarction at 30days or 6 to 12month follow up. In conclusion, our meta-analysis shows that DAPT after TAVI does not confer any additional benefit over SAPT in TAVI.

Section snippets

Methods

We performed a systematic literature review in PubMed, MEDLINE, SCOPUS, and Cochrane for all the related articles until December 2017. Search terms included “TAVR,” “TAVI,” “Transcatheter aortic valve replacement,” “antithrombotic agents,” “antiplatelet agents,” “dual antiplatelet therapy,” “single antiplatelet,” “aspirin,” and “DAPT”. All the results were downloaded to EndNote; a citation manager and duplicate citations were removed. We included all randomized controlled trials (RCT) and

Results

Three randomized trials6, 7, 8 and 4 nonrandomized studies4, 5,10, 11 involving 1,389 patients were included, of which 772 patients received DAPT and 617 received SAPT. The baseline characteristics were similar between the 2 treatment arms. The mean age of the population studied was 82years and included 55.6% females. Two studies5, 6 used Medtronic CoreValve only and 3 studies7, 8,10 used Edward's SAPIEN XT valve whereas Durand et al4 used both Medtronic CoreValve and Edward's SAPIEN XT valve (

Discussion

In this meta-analysis, we analyzed the outcomes at 30days and up to 6 to 12 months from all the RCTs and observational studies that compared DAPT to SAPT after TAVI. The results of our study show that DAPT after TAVI significantly increases LTB and significant bleeding when compared with SAPT without any benefit in ischemic and thromboembolic endpoints.

The rate of stroke after TAVI in various trials has been reported to be 1.2% to 6%.14, 15, 16 Stroke after TAVI is classified as acute (<24

Disclosures

The authors have no conflicts of interest to disclose.

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  • Cited by (11)

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    Funding: The study and the authors did not receive any financial support.

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