Ranking Antithrombotic Regimens After Transcatheter Aortic Valve Implantation

Based on a network meta-analysis of randomized controlled trials, Yijun Ke and colleagues concluded that single antiplatelet therapy (SAPT) should be the preferred antithrombotic strategy after transcatheter aortic valve implantation (TAVI) surgery, so long as there are no indications for oral anticoagulant (OAC) or dual antiplatelet therapy (DAPT). Their results were published in the International Journal of Cardiology.

The study included six randomized controlled trials with 2,824 total patients who underwent TAVI. The primary measures of the study were all-cause mortality, stroke, myocardial infarction, all bleeding, and life-threatening or major bleeding events. Antithrombotic strategies were ranked based on surface under the cumulative ranking (SUCRA) curves.

According to the report, DAPT had significantly higher risk of all bleeding (relative risk [RR] 2.03 [1.34-2.64]) and life-threatening/major bleeding (RR 2.03 [1.27-3.24]) compared to SAPT; however, there were no significant differences in all-cause mortality risk (RR 1.01 [0.61-1.68)] between the two strategies.  Notably, OAC plus SAPT (OACSAPT) was associated with significantly higher rates of all bleeding and life-threatening or major bleeding events compared to SAPT (RR 3.46 [2.23-5.36]; RR 2.86 [1.50-5.45]).

Additionally, OACSAPT carried a significantly higher risk of all-cause mortality (RR 1.72 [1.14-2.59]), and all bleeding (RR 1.84 [1.38-2.44]) compared to DAPT, though there was no significant difference between the two for risk of life-threatening or major bleeding events (RR 1.41 [0.89-2.23]). Notably, OACSAPT carried the highest risk for all-cause mortality (SUCRA 3.5%), and life-threatening or major bleeding (SUCRA 2.3%). Lastly, SAPT appeared to be superior to DAPT for all-cause mortality (SUCRA 76.7% vs. 69.8%), and stroke (SUCRA 69.6% vs. 59.7%).

In summary, the authors noted that, except for OACSAPT having higher all-cause mortality rates than DAPT, the different antithrombotic strategies had comparable all-cause mortality, stroke, and myocardial infarction rates. Furthermore, they noted, “the application of OACSAPT was ranked the worst among all antithrombotic regimens and should be averted due to an increased risk of all-cause mortality and all bleeding.”