Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy.
Thromb Haemost. 2022 Feb;122(2):216-225. doi: 10.1055/a-1496-8114. Epub 2021 Jun 15.
The optimal pharmacological therapy after transcatheter aortic valve implantation (TAVI) remains uncertain. We compared efficacy and safety of various antiplatelet and anticoagulant approaches after TAVI by a network meta-analysis.
A total of 14 studies (both observational and randomized) were considered, with 24,119 patients included. Primary safety endpoint was the incidence of any bleeding complications during follow-up. Secondary safety endpoint was major bleeding. Efficacy endpoints were stroke, myocardial infarction, and cardiovascular mortality. A frequentist network meta-analysis was conducted with a random-effects model. The following strategies were compared: dual antiplatelet therapy (DAPT), single antiplatelet therapy (SAPT), oral anticoagulation (OAC), and OAC + SAPT. The mean follow-up was 15 months.
In comparison to DAPT, SAPT was associated with a 44% risk reduction of any bleeding (odds ratio [OR]: 0.56 [95% confidence interval, CI: 0.39-0.80]). SAPT was ranked as the safest strategy for the prevention of any bleeding (-score: 0.704), followed by OAC alone (-score: 0.476) and DAPT (-score: 0.437). Consistent results were observed for major bleeding. The incidence of cardiovascular death and secondary ischemic endpoints did not differ among the tested antithrombotic approaches. In patients with indication for long-term anticoagulation, OAC alone showed similar rates of stroke (OR: 0.92 [95% CI: 0.41-2.05], = 0.83) and reduced occurrence of any bleeding (OR: 0.49 [95% CI: 0.37-0.66], < 0.01) versus OAC + SAPT.
The present network meta-analysis supports after TAVI the use of SAPT in patients without indication for OAC and OAC alone in those needing long-term anticoagulation.
经导管主动脉瓣置换术（TAVI）后的最佳药物治疗仍不确定。我们通过网络荟萃分析比较了 TAVI 后各种抗血小板和抗凝方法的疗效和安全性。
共纳入 14 项研究（包括观察性和随机研究），共纳入 24119 例患者。主要安全性终点是随访期间任何出血并发症的发生率。次要安全性终点是大出血。疗效终点是卒中和心肌梗死以及心血管死亡率。使用随机效应模型进行了频率论网络荟萃分析。比较了以下策略：双联抗血小板治疗（DAPT）、单联抗血小板治疗（SAPT）、口服抗凝剂（OAC）和 OAC+SAPT。平均随访时间为 15 个月。
与 DAPT 相比，SAPT 可使任何出血的风险降低 44%（比值比 [OR]：0.56 [95%置信区间，CI：0.39-0.80]）。SAPT 被认为是预防任何出血的最安全策略（-评分：0.704），其次是单独使用 OAC（-评分：0.476）和 DAPT（-评分：0.437）。在主要出血方面也观察到了一致的结果。测试的抗血栓形成方法之间的心血管死亡和二级缺血终点发生率没有差异。对于需要长期抗凝的患者，单独使用 OAC 的卒中发生率相似（OR：0.92 [95% CI：0.41-2.05]，=0.83），且任何出血的发生率降低（OR：0.49 [95% CI：0.37-0.66]，<0.01），而不是 OAC+SAPT。
本网络荟萃分析支持在无 OAC 指征的 TAVI 后患者中使用 SAPT，以及在需要长期抗凝的患者中单独使用 OAC。
