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Background <p>Severe aortic stenosis (SAS) is a critical condition with high morbidity and mortality if left untreated. Transcatheter aortic valve implantation (TAVI) has emerged as a transformative therapy, especially for patients at high or intermediate surgical risk. However, the optimal post-TAVI antithrombotic therapy remains a subject of debate due to the need to balance thromboembolic prevention with bleeding risks. Current guidelines provide weak recommendations for dual antiplatelet therapy (DAPT) and anticoagulation regimens, reflecting the lack of consensus and robust comparative data.</p> Objective <p>This network meta-analysis (NMA) aimed to compare the efficacy and safety of five antithrombotic regimens, including single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), oral anticoagulants (OAC), new oral anticoagulants (NOAC), and OAC combined with SAPT (OAC + SAPT) in patients undergoing TAVI. The primary outcomes were all-cause mortality and major bleeding, while secondary outcomes included cardiovascular mortality, stroke/transient ischemic attack (TIA), and myocardial infarction (MI).</p> Methods <p>A comprehensive systematic search was conducted in PubMed, Embase, and Web of Science up to Nov 2024. 11 studies involving 6,547 patients were included in this NMA. Outcomes were analyzed using a frequentist NMA approach, and treatments were ranked using surface under the cumulative ranking curve (SUCRA) probabilities.</p> Results <p>SAPT was the most effective regimen in reducing all-cause mortality (OR 0.57, 95% CI 0.38–0.85; SUCRA 85.0%) and major bleeding events (SUCRA 93.8%). DAPT ranked highest for reducing cardiovascular mortality (SUCRA 68.7%), while OAC + SAPT showed superiority in preventing stroke/TIA (SUCRA 76.1%). SAPT also ranked highest in reducing MI risk (SUCRA 69.2%). In contrast, NOAC and OAC were associated with higher bleeding risks and limited mortality benefits, positioning them as less favorable options in this analysis.</p> Conclusions <p>This study provides compelling evidence supporting SAPT as the preferred antithrombotic regimen for most TAVI patients, given its consistent performance in reducing all-cause mortality, MI, and major bleeding events. DAPT may be a suitable alternative for patients at elevated risk of cardiovascular death, while OAC + SAPT offers potential benefits in reducing stroke/TIA risks but requires careful consideration due to its higher bleeding risk. NOAC and OAC alone were associated with increased bleeding complications and limited efficacy, highlighting the need for cautious application in specific patient subgroups.</p>

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The efficacy and safety of antithrombotic therapy in patients undergoing TAVI: a network meta-analysis

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年7月4日

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  • Jingxian Han,
  • Keyao Liu,
  • Yuxin Li,
  • Dong Han,
  • Pengchong Liang,
  • Ningjun Zhao,
  • Shuqun Hu,
  • Xianliang Yan

摘要

Background

Severe aortic stenosis (SAS) is a critical condition with high morbidity and mortality if left untreated. Transcatheter aortic valve implantation (TAVI) has emerged as a transformative therapy, especially for patients at high or intermediate surgical risk. However, the optimal post-TAVI antithrombotic therapy remains a subject of debate due to the need to balance thromboembolic prevention with bleeding risks. Current guidelines provide weak recommendations for dual antiplatelet therapy (DAPT) and anticoagulation regimens, reflecting the lack of consensus and robust comparative data.

Objective

This network meta-analysis (NMA) aimed to compare the efficacy and safety of five antithrombotic regimens, including single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), oral anticoagulants (OAC), new oral anticoagulants (NOAC), and OAC combined with SAPT (OAC + SAPT) in patients undergoing TAVI. The primary outcomes were all-cause mortality and major bleeding, while secondary outcomes included cardiovascular mortality, stroke/transient ischemic attack (TIA), and myocardial infarction (MI).

Methods

A comprehensive systematic search was conducted in PubMed, Embase, and Web of Science up to Nov 2024. 11 studies involving 6,547 patients were included in this NMA. Outcomes were analyzed using a frequentist NMA approach, and treatments were ranked using surface under the cumulative ranking curve (SUCRA) probabilities.

Results

SAPT was the most effective regimen in reducing all-cause mortality (OR 0.57, 95% CI 0.38–0.85; SUCRA 85.0%) and major bleeding events (SUCRA 93.8%). DAPT ranked highest for reducing cardiovascular mortality (SUCRA 68.7%), while OAC + SAPT showed superiority in preventing stroke/TIA (SUCRA 76.1%). SAPT also ranked highest in reducing MI risk (SUCRA 69.2%). In contrast, NOAC and OAC were associated with higher bleeding risks and limited mortality benefits, positioning them as less favorable options in this analysis.

Conclusions

This study provides compelling evidence supporting SAPT as the preferred antithrombotic regimen for most TAVI patients, given its consistent performance in reducing all-cause mortality, MI, and major bleeding events. DAPT may be a suitable alternative for patients at elevated risk of cardiovascular death, while OAC + SAPT offers potential benefits in reducing stroke/TIA risks but requires careful consideration due to its higher bleeding risk. NOAC and OAC alone were associated with increased bleeding complications and limited efficacy, highlighting the need for cautious application in specific patient subgroups.