November 10, 2015 – The optimal treatment for atrial fibrillation patients who have undergone transcatheter aortic valve replacement remains unclear.
Atrial fibrillation (AF) is highly common in patients who have undergone transcatheter aortic valve replacement (TAVR), and is strongly associated with worse outcomes for these patients, according to a new study.
The results of that study were presented Tuesday at the annual Scientific Sessions of the American Heart Association in Orlando, Florida.
Earlier research has established that AF is common among TAVR patients. However, it has been unclear exactly how prevalent the condition is among this patient population. There is also little evidence on the optimal antithrombotic therapy in TAVR patients, particularly those with AF.
To address these questions, the DCRI’s Matthew Sherwood, MD, and his colleagues analyzed data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVR) Registry. The registry contains data on patient demographics, procedure details, and facility and physician information related to TVT.
The final patient population for the study included more than 16,000 patients at 329 sites who underwent TAVR between 2011 and 2014.
Sherwood and his team found that almost one half of the TAVR patients (45 percent) had preoperative AF. Patients with AF were also at significantly higher risk for death and bleeding, although the risk of stroke remained similar for patients with AF and those without.
The researchers also examined the use of anticoagulant and antiplatelet agents among TAVR patients. Only 53 percent of patients with AF were discharged on oral anticoagulation. Among patients on oral anticoagulation, nearly 75 percent of patients were also discharged on antiplatelet monotherapy. A much smaller number of patients (16 percent) were discharged on triple therapy, and a minority of patients were discharged on no additional antiplatelet therapy.
For those who did not receive oral anticoagulation at discharge, 61 percent of these
patients were discharged on dual antiplatelet therapy. A quarter of patients were discharged on antiplatelet monotherapy alone, and surprisingly, 14 percent of the patients with AF who did not receive oral anticoagulation also did not receive any antiplatelet therapy.
Despite variability in use or oral anticoagulation, there were no differences in 1-year hazard for mortality, stroke, or bleeding events between patients who received anticoagulation versus those who did not. Further studies are needed to define the best antithrombotic medical treatment following TAVR, especially in AF patients, the researchers concluded.
“There is great variability in the type of medication received,” Sherwood said. “The next step would be a randomized clinical trial to determine the optimal treatment for these patients.”
In addition to Sherwood, Duke authors included Sreekanth Vemulapalli, MD; Dadi Dai, PhD; Amit N. Vora, MD, MPH; Kevin Harrison, MD; and Eric D. Peterson, MD, MPH.