Division of Cardiology, Loyola University Medical Center, Maywood, Illinois.
Division of Cardiology, University of Toronto, Toronto, Ontario, Canada.
Am J Cardiol. 2018 Jul 1;122(1):141-148. doi: 10.1016/j.amjcard.2018.03.019. Epub 2018 Mar 28.
Current guidelines recommend dual-antiplatelet therapy (DAPT) after transcatheter aortic valve implantation (TAVI), although some studies suggest mono-antiplatelet therapy is equally efficacious with an improved safety profile. We performed a meta-analysis of studies comparing DAPT with mono-antiplatelet therapy after TAVI. Study quality and heterogeneity were assessed using Jadad score, Newcastle-Ottawa Scale, and Cochran's Q statistics. Mantel-Haenszel odds ratios (ORs) were calculated using fixed effect models as the primary analysis. Eight studies including 2,439 patients met the inclusion criteria. At 30 days, DAPT was associated with an increased risk of all-cause mortality (OR 2.06, 95% confidence interval [CI] 1.34 to 3.18, p = 0.001), major or life-threatening bleeding (OR 2.04, 95% CI 1.60 to 2.59, p <0.001), and major vascular complications (OR 2.15, 95% CI 1.51 to 3.06, p <0.001). There was no difference in the rate of the combined end point of stroke or transient ischemic attack, or myocardial infarction. Outcome data up to 6 months were available in 5 studies; all-cause mortality and stroke were similar between groups, although major or life-threatening bleeding was more frequent with DAPT. In conclusion, in patients undergoing TAVI, DAPT is associated with increased risk at 30 days of all-cause mortality, major or life-threatening bleeding, and major vascular complications without a decrease in ischemic complications; at 6 months, the excess bleeding risk persisted. These data suggest a safety concern with DAPT and justify further investigation of the optimal antiplatelet therapy regimen after TAVI.
目前的指南建议经导管主动脉瓣植入术(TAVI)后进行双联抗血小板治疗(DAPT),尽管一些研究表明,与 DAPT 相比,单联抗血小板治疗同样有效且安全性更高。我们对 TAVI 后 DAPT 与单联抗血小板治疗进行了荟萃分析。使用 Jadad 评分、纽卡斯尔-渥太华量表和 Cochran's Q 统计量评估研究质量和异质性。使用固定效应模型计算 Mantel-Haenszel 比值比(OR)作为主要分析。八项研究共纳入 2439 例患者符合纳入标准。在 30 天内,DAPT 与全因死亡率增加相关(OR 2.06,95%置信区间[CI] 1.34 至 3.18,p=0.001)、主要或危及生命的出血(OR 2.04,95%CI 1.60 至 2.59,p<0.001)和主要血管并发症(OR 2.15,95%CI 1.51 至 3.06,p<0.001)。卒中或短暂性脑缺血发作或心肌梗死的联合终点发生率无差异。5 项研究提供了长达 6 个月的结局数据;两组全因死亡率和卒中相似,尽管 DAPT 组主要或危及生命的出血更为常见。总之,在接受 TAVI 的患者中,DAPT 在 30 天内与全因死亡率、主要或危及生命的出血和主要血管并发症增加相关,而缺血性并发症无减少;在 6 个月时,出血风险仍持续增加。这些数据表明 DAPT 存在安全性问题,需要进一步研究 TAVI 后最佳抗血小板治疗方案。