Antithrombotic Therapy and Cardiovascular Outcomes After Transcatheter Aortic Valve Replacement in Patients With Atrial Fibrillation
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Published on: July 20, 2022
Ioanna Kosmidou1, Yangbo Liu2, Maria C Alu3
1Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York.
Insights
For patients with atrial fibrillation (AF) undergoing transcatheter aortic valve replacement (TAVR), antiplatelet therapy, with or without oral anticoagulants, reduced stroke risk. This suggests complex stroke causes in this patient group.
Area of Science:
- Cardiology
- Vascular Medicine
- Interventional Cardiology
Background:
- The optimal antithrombotic strategy post-transcatheter aortic valve replacement (TAVR) for patients with atrial fibrillation (AF) and high stroke risk (CHA 2 DS 2 -VASc score ≥2) remains unclear.
- Understanding these patterns is crucial for improving clinical outcomes in this vulnerable population.
Purpose of the Study:
- To investigate antithrombotic therapy patterns in patients with AF and CHA 2 DS 2 -VASc score ≥2 undergoing TAVR.
- To determine the association between different antithrombotic regimens and clinical outcomes, specifically stroke and death.
Main Methods:
- Analysis of 1,621 patients with prior AF and CHA 2 DS 2 -VASc score ≥2 from the PARTNER II trial and registries.
- Outcomes were stratified based on the antithrombotic therapy received: oral anticoagulant therapy (OAC), antiplatelet therapy (APT), or combination (OAC+APT).
- Clinical outcomes, including stroke and the composite of death or stroke, were assessed at 2 years post-TAVR.
Main Results:
- 57.6% of patients received OAC post-TAVR.
- OAC combined with APT was associated with a significantly reduced rate of stroke (5.4% vs. 11.1%; p=0.03) and death or stroke (29.7% vs. 40.1%; p=0.01) compared to no OAC or APT.
- Adjusted analysis confirmed that OAC+APT and APT alone were associated with reduced stroke risk compared to no antithrombotic therapy.
Conclusions:
- In patients with AF undergoing TAVR, utilizing antiplatelet therapy, either alone or with oral anticoagulants, is linked to a lower risk of stroke.
- These findings highlight the multifactorial nature of stroke in this population and support the use of combined or antiplatelet-only strategies.
Objectives:
The study sought to determine the patterns of antithrombotic therapy and association with clinical outcomes in patients with atrial fibrillation (AF) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score ≥2 following transcatheter aortic valve replacement (TAVR).
Background:
The impact of antithrombotic regimens on clinical outcomes in patients with AF and severe aortic stenosis treated with TAVR is unknown.
Methods:
In the randomized PARTNER II (Placement of Aortic Transcatheter Valve II) trial and associated registries, 1,621 patients with prior AF and CHA2DS2-VASc score ≥2 comprised the study cohort. Outcomes were analyzed according to antithrombotic therapy.
Results:
During the 5-year enrollment period, 933 (57.6%) patients were discharged on oral anticoagulant therapy (OAC). Uninterrupted antiplatelet therapy (APT) for at least 6 months or until an endpoint event was used in 544 of 933 (58.3%) of patients on OAC and 77.5% of patients not on OAC. At 2 years, patients on OAC had a similar rate of stroke (6.6% vs. 5.6%; p = 0.53) and the composite outcome of death or stroke (29.7% vs. 31.8%; p = 0.33), compared with no OAC. OAC with APT was associated with a reduced rate of stroke (5.4% vs. 11.1%; p = 0.03) and death or stroke (29.7% vs. 40.1%; p = 0.01), compared with no OAC or APT. Following adjustment, OAC with APT and APT alone were both associated with reduced rates of stroke compared with no OAC or APT (hazard ratio for OAC+APT: 0.43, 95% confidence interval: 0.22 to 0.85; p = 0.015; hazard ratio for APT alone: 0.32, 95% confidence interval: 0.16 to 0.65; p = 0.002), while OAC alone was not.
Conclusions:
Among patients with prior AF undergoing TAVR, antiplatelet with or without anticoagulant therapy was associated with a reduced risk of stroke at 2 years, implicating multifactorial stroke mechanisms in this population.
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