非适应证患者经导管主动脉瓣置换术后的抗栓治疗：更新的系统评价和网状Meta分析
Post-Transcatheter Aortic Valve Replacement Antithrombotic Treatment in Nonindicated Patients: Updated Systematic Review and Network Meta-Analysis.
作者信息
Siami Sahand, Kazemian Sina, Maleki Saba, Ebrahimi Elham, Jodeiri Fatemeh, Ebrahimzade Mandana, Hajiqasemi Mohsen, Ebrahimi Sara, Mehdizadeh Maede, Aghaei Mona, Bastan Mohammad-Mahdi, Fathian Sabet Mehrshad, Nazari Roozbeh, Ebrahimi Pouya, Rana Jamal S, Nanna Michael G, Giri Jay, Kolte Dhaval, Biering-Sørensen Tor, Alkhouli Mohamad, Hosseini Kaveh
机构信息
Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; School of Medicine, Islamic Azad University, Tehran Medical Branch, Tehran, Iran.
Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
出版信息
JACC Adv. 2025 Mar 31;4(5):101719. doi: 10.1016/j.jacadv.2025.101719.
BACKGROUND
The optimal antithrombotic strategy following transcatheter aortic valve replacement (TAVR) remains controversial.
OBJECTIVES
The authors aimed to determine the safety and efficacy of various antithrombotic regimens in patients without an indication for anticoagulation following TAVR.
METHODS
We conducted a systematic search in PubMed, Embase, Scopus, and ClinicalTrials.gov until August 2024 for studies investigating antithrombotic regimens after TAVR in patients without an indication for chronic oral anticoagulation. The analysis compared single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), direct oral anticoagulants, and oral anticoagulant (OAC) plus SAPT. A frequentist network meta-analysis was employed to evaluate the post-TAVR risk of all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, total bleeding, and life-threatening or major bleeding.
RESULTS
Eleven studies (8 randomized controlled trials and 3 propensity score-matched cohorts) comprising 5,821 patients undergoing TAVR were included. SAPT significantly reduced the risk of life-threatening/major bleeding compared with DAPT (OR: 0.53; 95% CI: 0.35-0.80), OAC (OR: 0.52; 95% CI: 0.28-0.99), and OAC + SAPT (OR: 0.32; 95% CI: 0.13-0.76). No significant differences were observed in the risk of cardiovascular mortality, stroke, or myocardial infarction between antithrombotic regimens. Subgroup analysis indicated an increased risk of mortality with low-dose rivaroxaban+3-month SAPT compared with SAPT (OR: 0.56; 95% CI: 0.35-0.89) and DAPT (OR: 0.58; 95% CI: 0.38-0.88). Meta-regression identified chronic obstructive pulmonary disease as the only significant modifier of bleeding risk following TAVR.
CONCLUSIONS
Our findings support current guidelines recommending SAPT as the preferred antithrombotic strategy post-TAVR in patients without an indication for anticoagulation, demonstrating optimal safety without compromising efficacy.
背景
经导管主动脉瓣置换术（TAVR）后的最佳抗栓策略仍存在争议。
目的
作者旨在确定TAVR后无抗凝指征患者中各种抗栓方案的安全性和有效性。
方法
我们在PubMed、Embase、Scopus和ClinicalTrials.gov进行了系统检索，直至2024年8月，以查找关于无慢性口服抗凝指征患者TAVR后抗栓方案的研究。该分析比较了单一抗血小板治疗（SAPT）、双重抗血小板治疗（DAPT）、直接口服抗凝药以及口服抗凝药（OAC）加SAPT。采用频率学派网状Meta分析来评估TAVR后全因死亡、心血管死亡、心肌梗死、卒中、总出血以及危及生命或大出血的风险。
结果
纳入了11项研究（8项随机对照试验和3项倾向评分匹配队列），共5821例接受TAVR的患者。与DAPT（比值比：0.53；95%置信区间：0.35 - 0.80）、OAC（比值比：0.52；95%置信区间：0.28 - 0.99）和OAC + SAPT（比值比：0.32；95%置信区间：0.13 - 0.76）相比，SAPT显著降低了危及生命/大出血的风险。抗栓方案之间在心血管死亡、卒中或心肌梗死风险方面未观察到显著差异。亚组分析表明，与SAPT（比值比：0.56；95%置信区间：0.35 - 0.89）和DAPT（比值比：0.58；95%置信区间：0.38 - 0.88）相比，低剂量利伐沙班 + 3个月SAPT的死亡风险增加。Meta回归确定慢性阻塞性肺疾病是TAVR后出血风险的唯一显著调节因素。
结论
我们的研究结果支持当前指南推荐SAPT作为无抗凝指征患者TAVR后首选的抗栓策略，表明其在不影响疗效的情况下具有最佳安全性。
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