Antiagregación doble frente a simple, con o sin anticoagulación, tras reemplazo percutáneo de válvula aórtica: comparación indirecta y metanálisis

Comparing Single- and Dual Antiplatelet Therapies Following Transcatheter Aortic Valve Implantation

BACKGROUND

Transcatheter aortic valve implantation has been an established treatment in patients with symptomatic severe aortic stenosis. However, the postoperative antiplatelet regimen after transcatheter aortic valve implantation was not established certainly. The aim of this meta-analysis is to compare the safety and efficacy of single- (SAPT) and dual-antiplatelet therapies (DAPT) in patients undergoing transcatheter aortic valve implantation.

METHODS

Eligible randomized controlled trials and cohort studies published before February 2021 were retrieved from PubMed, Embase, and the Cochrane Library. We calculated odds ratios with 95% confidence intervals.

RESULTS

Nine articles, involving 19,277 patients, met the selection criteria. In the short-term outcome, compared with SAPT, DAPT was associated with a significantly higher rate of bleeding (odds ratios, 95% confidence intervals: 3.00, 1.67-5.38) and showed no significant differences in thrombotic events (odds ratios, 95% confidence intervals: 1.25, 0.74-2.11) and all-cause mortality (odds ratios, 95% confidence intervals: 0.84; 0.42-1.69). In the long-term outcome, DAPT was associated with a significantly higher bleeding rate (odds ratios, 95% confidence intervals: 1.85, 1.24-2.78) and showed no differences in thrombotic events (odds ratios, 95% confidence intervals: 1.13, 0.86-1.48) and all-cause mortality (odds ratios, 95% confidence intervals: 1.12, 0.95-1.32). Our trial sequential analysis confirmed DAPT didn't confer any benefit for reducing all-cause mortality and thrombotic events, and carried a higher risk of bleeding than SAPT.

CONCLUSIONS

SAPT should be a sufficient antiplatelet strategy in post- transcatheter aortic valve implantation patients without indications for oral anticoagulation medication, especially in the long-term follow-up period.

Aspirin Versus Dual Antiplatelet Therapy in Patients Undergoing Trans-Catheter Aortic Valve Implantation, Updated Meta-Analysis

BACKGROUND

The Antiplatelet Therapy for Patients Undergoing Transcatheter Aortic-Valve Implantation (POPular TAVI) trial reported comparable composite endpoints of ischemic events using aspirin compared to dual antiplatelet therapy (DAPT). However, this trial was not powered to detect individual differences in ischemic events. We sought to conduct a meta-analysis to compare aspirin to DAPT on ischemic and bleeding events following TAVI.

METHODS

The MEDLINE database was searched from inception until September 2020 and only randomized clinical trials of patients receiving antiplatelet therapy following TAVI were included. The treatment effect was reported as rate ratios (RRs) with 95% confidence intervals.

RESULTS

Four randomized clinical trials of 1086 TAVI patients were included. There was a 51% reduction in major or life-threatening bleeding with aspirin compared with DAPT [RR 0.49, (95%CI 0.31 to 0.78)]. Aspirin was not associated with an increased risk of death [RR 1.01, (95%CI 0.62 to 1.65)], cardiovascular death [RR 1.15, (95%CI 0.56 to 2.36)], ischemic stroke [RR 0.93, (95%CI 0.51 to 1.70)], or MI [RR 0.53, (95%CI 0.18 to 1.57)].

CONCLUSIONS

This meta-analysis supports the use of aspirin as the optimal antiplatelet strategy following TAVI procedures in reducing bleeding without an increase in ischemic events compared with dual antiplatelet therapy.

Evaluating Effectiveness and Safety in Chronic Kidney Disease with Atrial Flutter Using an Anticoagulation Strategy

Background and objectives: Recent randomized trials of oral antithrombotic drugs with atrial flutter (AFL) excluded patients with renal impairment because of their increased risk of bleeding. To date, no relevant studies have assessed the effectiveness and safety of different antithrombotic drugs in chronic kidney disease (CKD) patients with AFL. This cohort study evaluated the effectiveness and safety of different antithrombotic drugs in CKD patients with AFL. This study also investigated the risk of cardiovascular events from antithrombotic drugs through different risk profiles of stroke stratified by the CHA₂DS₂-VASc score. Materials and Methods: This cohort study was performed in patients with AFL and CKD who were extracted from the National Health Insurance (NHI) Database in Taiwan. Oral antithrombotic therapy (oral anticoagulants (OAC) or antiplatelets (APT)) was administered to patients who had been diagnosed with AFL after being diagnosed with CKD between 2011 and 2015. Primary outcomes, including ischemic stroke, systemic embolism, and composite of stroke, and secondary outcomes, including major adverse cardiac events (MACEs), major bleeding, all-cause mortality, and cardiovascular-related death, were examined. Results: A total of 2468 patients were included in this study. The results showed no statistically significant differences in the risk of primary outcomes. For the secondary outcomes, there were also no statistically significant differences in the risk of MACEs and major bleeding. However, the pooled results indicated that the hazard ratio (HR) for all-cause mortality with OAC was 0.24 (95% confidence interval (CI) = 0.10–0.55) compared with combination therapy, and the HR for APT compared with OAC was 2.86 (95% CI = 1.48–5.53). Conclusions: In the studied population, OAC or APT alone were proved equally effective for stroke prophylaxis. Furthermore, OAC might reduce the all-cause mortality rate compared with APT and should be considered as the first choice of oral antithrombotic drugs in patients with AFL and CKD.