title: Pharmacological management strategies for stroke prevention following transcatheter aortic valve replacement: A systematic review.
abstract: BACKGROUND
  The most appropriate pharmacological treatment for stroke prevention after transcatheter aortic valve replacement (TAVR) is unclear. We performed a systematic review of randomized controlled trials (RCTs) and observational studies examining the effect of various pharmacological treatment regimens on rates of stroke, bleeding, and death after TAVR.
  
  
  METHODS
  We searched Cochrane Library, Embase, and Medline for RCTs and observational studies comparing ≥2 antithrombotic regimens in TAVR patients. Included antithrombotic regimens were defined as one or more antiplatelet agents (aspirin, clopidogrel, prasugrel, or ticagrelor) and/or anticoagulants (vitamin K antagonists or novel oral anticoagulants).
  
  
  RESULTS
  Eight studies (2 RCTs and 6 observational studies) met our inclusion criteria (n=1598). Rates of major stroke ranged from 0% to 5.6% with no detected differences between treatment arms. All-cause mortality ranged from 5% to 15%, and no differences in mortality were detected between therapies. A consistent pattern of reduction in major or life-threatening bleeding was found with a single antiplatelet therapy (SAPT) compared to dual antiplatelet therapy (DAPT). However, this difference only reached statistical significance in a single cohort study (risk ratio 0.24; 95% confidence interval 0.12, 0.46). No differences between anticoagulant therapies were detected for any endpoint. Overall, studies were underpowered to detect differences between treatment groups.
  
  
  CONCLUSIONS
  Similar rates of stroke, bleeding, and mortality were found among most studies. A trend towards reduced rates of major or life-threatening bleeding when comparing SAPT to DAPT was found. Numbers of events were small, highlighting the need for larger studies on which to base pharmacological recommendations post-TAVR.
authors.affiliation: Division of Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital/McGill University, Montreal, QC, Canada; Faculty of Medicine, McGill University, Montreal, QC, Canada.
authors.forename: Lee H
authors.initials: LH
authors.lastname: Sterling
authors.affiliation: Division of Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital/McGill University, Montreal, QC, Canada.
authors.forename: Sarah B
authors.initials: SB
authors.lastname: Windle
authors.affiliation: Division of Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital/McGill University, Montreal, QC, Canada; Faculty of Medicine, McGill University, Montreal, QC, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
authors.forename: Kristian B
authors.initials: KB
authors.lastname: Filion
authors.affiliation: Division of Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital/McGill University, Montreal, QC, Canada; Faculty of Medicine, McGill University, Montreal, QC, Canada; Division of Cardiology, Jewish General Hospital/McGill University, Montreal, QC, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada. Electronic address: mark.eisenberg@mcgill.ca.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Eisenberg
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D002986:Clinical Trials as Topic / Q000379:methods; D015331:Cohort Studies; D019468:Disease Management; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D064887:Observational Studies as Topic / Q000379:methods; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control*; D020521:Stroke / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control*; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects* / Q000639:trends
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors
keywords: Antithrombotic; Aortic stenosis; Bleeding; Stroke; Systematic review; Transcatheter aortic valve replacement