1. Warfarin and Antiplatelet Therapy Versus Warfarin Alone for Treating Patients With Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement
- Author
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Joelle Kefer, Maria del Rosario Ortas-Nadal, Ignacio J. Amat-Santos, Francisco Campelo-Parada, Antonio J. Muñoz-García, Luis Nombela-Franco, Ander Regueiro, Jaime Elízaga, Eric Dumont, Luis M. Benitez, Bruno García del Blanco, Asim N. Cheema, Vicenç Serra, Omar Abdul-Jawad Altisent, Antonio Dager, Rishi Puri, Josep Ramon Marsal, Enrique Gutiérrez, Sami Alnasser, Eric Durand, Maria Del Trigo, Hélène Eltchaninoff, Josep Rodés-Cabau, [Altisent, Omar Abdul-Jawad] Univ Laval, Quebec Heart & Lung Inst, Dept Cardiol, Quebec City, PQ, Canada, [del Rosario Ortas-Nadal, Maria] Univ Laval, Quebec Heart & Lung Inst, Dept Cardiol, Quebec City, PQ, Canada, [Campelo-Parada, Francisco] Univ Laval, Quebec Heart & Lung Inst, Dept Cardiol, Quebec City, PQ, Canada, [Regueiro, Ander] Univ Laval, Quebec Heart & Lung Inst, Dept Cardiol, Quebec City, PQ, Canada, [del Trigo, Maria] Univ Laval, Quebec Heart & Lung Inst, Dept Cardiol, Quebec City, PQ, Canada, [Dumont, Eric] Univ Laval, Quebec Heart & Lung Inst, Dept Cardiol, Quebec City, PQ, Canada, [Puri, Rishi] Univ Laval, Quebec Heart & Lung Inst, Dept Cardiol, Quebec City, PQ, Canada, [Rodes-Cabau, Josep] Univ Laval, Quebec Heart & Lung Inst, Dept Cardiol, Quebec City, PQ, Canada, [Durand, Eric] Hop Charles Nicolle, Univ Hosp Rouen, Dept Cardiol, Rouen, France, [Eltchaninoff, Helene] Hop Charles Nicolle, Univ Hosp Rouen, Dept Cardiol, Rouen, France, [Munoz-Garcia, Antonio J.] Univ Malaga, Hosp Univ Virgen de la Victoria, Dept Cardiol, Malaga, Spain, [Nombela-Franco, Luis] Hosp Univ Clin San Carlos, Dept Cardiol, Madrid, Spain, [Cheema, Asim] Univ Toronto, St Michaels Hosp, Dept Cardiol, Toronto, ON, Canada, [Alnasser, Sami M.] Univ Toronto, St Michaels Hosp, Dept Cardiol, Toronto, ON, Canada, [Kefer, Joelle] St Luc Univ Hosp, Dept Cardiol, Brussels, Belgium, [Gutierrez, Enrique] Inst Invest Sanitaria Gregorio Maranon, Dept Cardiol, Madrid, Spain, [Elizaga, Jaime] Inst Invest Sanitaria Gregorio Maranon, Dept Cardiol, Madrid, Spain, [Benitez, Luis M.] Clin Occidente Cali, Dept Cardiol, Valle Del Cauca, Colombia, [Dager, Antonio] Clin Occidente Cali, Dept Cardiol, Valle Del Cauca, Colombia, [Amat-Santos, Ignacio J.] Hosp Clin Univ Valladolid, Dept Cardiol, Valladolid, Spain, [Serra, Vicenc] Univ Autonoma Barcelona, Dept Cardiol, Hosp Univ Vall dHebron, Barcelona, Spain, [del Blanco, Bruno Garcia] Univ Autonoma Barcelona, Dept Cardiol, Hosp Univ Vall dHebron, Barcelona, Spain, [Ramon Marsal, Josep] Univ Autonoma Barcelona, Dept Cardiol, Hosp Univ Vall dHebron, Barcelona, Spain, [Ramon Marsal, Josep] CIBER Epidemiol & Publ Hlth CIBERESP, Barcelona, Spain, Alfonso Martin Escudero Foundation (Madrid, Spain), Edwards Lifesciences, Medtronic, and St. Jude Medical
- Subjects
Male ,Time Factors ,Vitamin K ,Heart Valve Diseases ,Kaplan-Meier Estimate ,Definitions ,030204 cardiovascular system & hematology ,Brain Ischemia ,0302 clinical medicine ,Risk Factors ,Atrial Fibrillation ,Antithrombotic ,Disease ,030212 general & internal medicine ,Stroke ,Aged, 80 and over ,Aspirin ,Hazard ratio ,Atrial fibrillation ,Vitamin K antagonist ,Clopidogrel ,stroke ,Implantation ,Management ,Europe ,Treatment Outcome ,Aortic Valve ,Oral anticoagulant-therapy ,Cardiology ,transcatheter aortic valve replacement ,Female ,Cardiology and Cardiovascular Medicine ,medicine.drug ,Risk ,Canada ,medicine.medical_specialty ,medicine.drug_class ,Hemorrhage ,03 medical and health sciences ,Internal medicine ,medicine ,Humans ,Society ,Aged ,Proportional Hazards Models ,Chi-Square Distribution ,business.industry ,Warfarin ,Anticoagulants ,medicine.disease ,bleeding ,warfarin ,Multivariate Analysis ,business ,Platelet Aggregation Inhibitors - Abstract
OBJECTIVES The study sought to examine the risk of ischemic events and bleeding episodes associated with differing antithrombotic strategies in patients undergoing transcatheter aortic valve replacement (TAVR) with concomitant atrial fibrillation (AF).BACKGROUND Guidelines recommend antiplatelet therapy (APT) post-TAVR to reduce the risk of stroke. However, data on the efficacy and safety of this recommendation in the setting of a concomitant indication for oral anticoagulation (due to atrial fibrillation [AF]) with a vitamin K antagonist (VKA) are scarce.METHODS A multicenter evaluation comprising 621 patients with AF undergoing TAVR was undertaken. Post-TAVR prescriptions were used to determine the antithrombotic regimen used according to the following 2 groups: monotherapy (MT) with VKA (n = 101) or multiple antithrombotic therapy (MAT) with VKA plus 1 or 2 antiplatelet agents (aspirin or clopidogrel; n = 520). Endpoint definitions were in accordance with Valve Academic Research Consortium-2 criteria. The rate of stroke, major adverse cardiovascular events (stroke, myocardial infarction, or cardiovascular death), major or life-threatening bleeding events, and death were assessed by a Cox multivariate model regression survival analysis according to the antithrombotic regime used.RESULTS During a median follow-up of 13 months (interquartile range: 3 to 31 months) there were no differences between groups in the rate of stroke (MT: 5%, MAT: 5.2%; adjusted hazard ratio [HR]: 1.25; 95% confidence interval [CI]: 0.45 to 3.48; p = 0.67), major adverse cardiovascular events (MT: 13.9%, MAT: 16.3%; adjusted HR: 1.33; 95% CI: 0.75 to 2.36; p = 0.33), and death (MT 22.8%, MAT: 19.2%; adjusted HR: 0.93; 95% CI: 0.58 to 1.50; p = 0.76). A higher risk of major or life-threatening bleeding was found in the MAT group (MT: 14.9%, MAT: 24.4%; adjusted HR: 1.85; 95% CI: 1.05 to 3.28; p = 0.04). These results remained similar when patients receiving VKA plus only 1 antiplatelet agent (n = 463) were evaluated.CONCLUSIONS In TAVR recipients prescribed VKA therapy for AF, concomitant antiplatelet therapy use appears not to reduce the incidence of stroke, major adverse cardiovascular events, or death, while increasing the risk of major or life-threatening bleeding. (C) 2016 by the American College of Cardiology Foundation.
- Published
- 2016