Thromb Haemost. 2021 Apr 30. doi: 10.1055/a-1496-8114. Online ahead of print.
BACKGROUND: The optimal pharmacological therapy after transcatheter aortic valve implantation (TAVI) remains uncertain. We compared efficacy and safety of various antiplatelet and anticoagulant approaches after TAVI by a network meta-analysis.
METHODS: A total of 14 studies (both observational and randomized) were considered, with 24,119 patients included. Primary safety endpoint was the incidence of any bleeding complications during follow-up. Secondary safety endpoint was major bleeding. Efficacy endpoints were stroke, myocardial infarction and cardiovascular mortality. A frequentist network meta-analysis was conducted with a random-effects model. The following strategies were compared: dual antiplatelet therapy (DAPT), single antiplatelet therapy (SAPT), oral anticoagulation (OAC), OAC+SAPT. Mean follow-up was 15 months.
RESULTS: In comparison to DAPT, SAPT was associated with a 44% risk reduction of any bleeding (OR, 0.56 [95% CI, 0.39-0.80]). SAPT was ranked as the safest strategy for the prevention of any bleeding (P-score, 0.704), followed by OAC alone (P-score, 0.476) and DAPT (P-score, 0.437). Consistent results were observed for major bleeding. The incidence of cardiovascular death and secondary ischemic endpoints did not differ among the tested antithrombotic approaches. In patients with indication for long-term anticoagulation, OAC alone showed similar rates of stroke (OR 0.92 [95% CI 0.41-2.05], p=0.83) and reduced occurrence of any bleeding (OR 0.49 [95% CI 0.37-0.66], p<0.01) vs OAC+SAPT.
CONCLUSIONS: The present network meta-analysis supports after TAVI the use of SAPT in patients without indication for OAC and OAC alone in those needing long-term anticoagulation.