Verdoia Monica, Barbieri Lucia, Nardin Matteo, Suryapranata Harry, De Luca Giuseppe
Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy; Department of Cardiology, Ospedale S. Andrea, Vercelli, Italy.
Rev Esp Cardiol (Engl Ed). 2018 Apr;71(4):257-266. doi: 10.1016/j.rec.2017.06.012. Epub 2017 Jul 19.
There is uncertainty on the correct management of antithrombotic therapies after transcatheter aortic valve replacement (TAVR), with dual antiplatelet therapy (DAPT) being currently recommended on an empirical basis. The aim of the present meta-analysis was to assess the safety and effectiveness of DAPT in patients undergoing TAVR.
Studies comparing different antithrombotic regimens after TAVR were included. The primary endpoint was 30-day overall mortality.
We included 9 studies, 5 comparing DAPT with aspirin monotherapy and 4 comparing DAPT with monoantiplatelet therapy (MAPT) + oral anticoagulation. Among 7991 patients, 72% were on DAPT. The median follow-up was 3.5 months. Mortality was significantly lower in the DAPT group (12.2% vs 14.4%; OR, 0.81; 95%CI, 0.70-0.93; P = .003; P = .93), with similar benefits compared with aspirin monotherapy (OR, 0.80; 95%CI, 0.69-0.93; P = .004; P = .60), which were not statistically significant when compared with MAPT + oral anticoagulation (OR, 0.86; 95%CI, 0.55-1.35; P = .51; P = .97). A similar trend for DAPT was observed for stroke (OR, 0.83 95%CI, 0.63-1.10; P = .20; P = .67), with no increase in the rate of major bleedings (OR, 1.69; 95%CI, 0.86-3.31; P = .13; P< .0001). On indirect comparison analysis, no benefit in survival, stroke, or bleedings was identified for additional oral anticoagulation.
The present meta-analysis supports the use of DAPT after TAVR, reducing mortality and offering slight benefits in stroke, with no increase in major bleedings compared with MAPT. The strategy of aspirin + oral anticoagulation did not provide significant benefits compared with MAPT or DAPT.
经导管主动脉瓣置换术（TAVR）后抗栓治疗的正确管理存在不确定性，目前经验性推荐双联抗血小板治疗（DAPT）。本荟萃分析的目的是评估TAVR患者中DAPT的安全性和有效性。
纳入比较TAVR后不同抗栓方案的研究。主要终点为30天全因死亡率。
我们纳入了9项研究，5项比较DAPT与阿司匹林单药治疗，4项比较DAPT与单重抗血小板治疗（MAPT）+口服抗凝治疗。在7991例患者中，72%接受DAPT治疗。中位随访时间为3.5个月。DAPT组的死亡率显著更低（12.2%对14.4%；OR，0.81；95%CI，0.70 - 0.93；P = 0.003；P = 0.93），与阿司匹林单药治疗相比有相似益处（OR，0.80；95%CI，0.69 - 0.93；P = 0.004；P = 0.60），与MAPT +口服抗凝治疗相比无统计学显著差异（OR，0.86；95%CI，0.55 - 1.35；P = 0.51；P = 0.97）。DAPT在卒中方面也观察到类似趋势（OR，0.83；95%CI，0.63 - 1.10；P = 0.20；P = 0.67），大出血发生率未增加（OR, 1.69；95%CI，0.86 - 3.31；P = 0.13；P < 0.0001）。间接比较分析显示，额外口服抗凝在生存、卒中和出血方面无益处。
本荟萃分析支持TAVR后使用DAPT，可降低死亡率并在卒中方面有轻微益处，与MAPT相比大出血发生率未增加。与MAPT或DAPT相比，阿司匹林+口服抗凝策略未提供显著益处。
