Comparison of Dual-antiplatelet Therapy to Mono-antiplatelet Therapy After Transcatheter Aortic Valve Implantation: Systematic Review and Meta-analysis.
BACKGROUND
Post-transcatheter aortic valve implantation (TAVI) dual-antiplatelet therapy (DAPT) with acetylsalicylic acid and clopidogrel is common practice to reduce ischemic complications despite the lack of clinical trial evidence demonstrating superiority over mono-antiplatelet therapy (MAPT).


METHODS
A systematic search was conducted to retrieve studies that investigated DAPT vs MAPT in patients who have undergone TAVI. Outcomes of interest included both ischemic and bleeding events at 30 days and 6 months.


RESULTS
Four studies met inclusion criteria-2 randomized control trials and 2 observational studies, with 286 patients in the DAPT group and 354 patients in the MAPT group. For the primary outcome of a combined end point of 30-day major stroke, spontaneous myocardial infarction (MI), all-cause mortality, and combined lethal and major bleeding, there was a trend toward increased harm in the DAPT group (29%) compared with the MAPT group (16%), with an odds ratio (OR) of 1.88 (P = 0.05). Secondary outcome analysis revealed that there was no significant difference between groups regarding 30-day stroke, 30-day spontaneous MI, and 30-day all-cause mortality. Patients who received DAPT had a significant increase in combined 30-day lethal and major bleeding (OR, 2.62; P = 0.008). Further analysis revealed that increased adverse events were driven by observational studies, with no difference in outcomes between groups in randomized controlled trials.


CONCLUSIONS
DAPT in patients who have undergone TAVI demonstrated no benefit over MAPT in reduction of ischemic events, with a trend toward increased harm because of bleeding. Future considerations should be given to MAPT with clopidogrel alone, as well as the omission of clopidogrel loading before the procedure.
Department of Medicine, Division of Cardiology, McMaster University, Hamilton, Ontario, Canada. Electronic address: sumeet.gandhi@medportal.ca.
Sumeet
S
Gandhi
Department of Medicine, Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
Jon-David R
JD
Schwalm
Department of Medicine, Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
James L
JL
Velianou
Department of Medicine, Division of Cardiology, and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
Madhu K
MK
Natarajan
Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre of Excellence, University of Toronto, Toronto, Ontario, Canada.
Michael E
ME
Farkouh
D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000601:surgery*; D001241:Aspirin / Q000627:therapeutic use*; D000077144:Clopidogrel; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000453:epidemiology / Q000517:prevention & control; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control; D011379:Prognosis; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control; D016019:Survival Analysis; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D016896:Treatment Outcome; D014463:Ultrasonography
D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin