Pharmacological management strategies for stroke prevention following transcatheter aortic valve replacement: A systematic review.

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.

CONCLUSION: 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.