Author + information
- Received May 29, 2018
- Revision received August 9, 2018
- Accepted August 13, 2018
- Published online January 7, 2019.
- Thomas G. Nührenberg, MD∗ (, )
- Julia Hromek, MD,
- Alexander Kille, MD,
- Willibald Hochholzer, MD,
- Manuel Hein, MD,
- Dietmar Trenk, PhD,
- Franz-Josef Neumann, MD,
- Christian Stratz, MD∗ and
- Philipp Ruile, MD∗
- University Heart Center Freiburg-Bad Krozingen, Department of Cardiology and Angiology II, Bad Krozingen, Germany
- ↵∗Address for correspondence:
Dr. Thomas G. Nührenberg, University Heart Center Freiburg-Bad Krozingen, Department of Cardiology and Angiology II, D-79189 Bad Krozingen, Germany.
Objectives To assess the impact of on-clopidogrel platelet reactivity (PR) on HALT, the authors prospectively tested whether patients with below-median on-clopidogrel PR have a lower incidence of HALT compared with those with above-median on-clopidogrel PR.
Background It is unclear whether the apparent ineffectiveness of clopidogrel in preventing hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVR) questions the concept of P2Y12 inhibition after TAVR or is a consequence of an inadequate response to clopidogrel in elderly patients with severe aortic stenosis.
Methods Patients were either on long-term dual antiplatelet therapy with clopidogrel and acetylsalicylic acid or were given bolus doses of both drugs the day before TAVR. Adenosine diphosphate (ADP)–induced multielectrode impedance aggregometry was performed before TAVR. After TAVR, clopidogrel was continued in all patients. Computed tomographic angiography was performed to detect HALT.
Results Of 331 patients enrolled, computed tomographic angiography was performed in 200 at 5 days (interquartile range: 4 to 6 days). Among patients with below-median ADP-induced PR (<180 AU · min), 16 were diagnosed with HALT, whereas 20 patients with above-median PR were diagnosed with HALT (p = 0.58). Among patients with high on-clopidogrel PR (>468 AU · min; n = 29), 7 (24%) displayed HALT, compared with 19 (17%) with ADP-induced PR ≤468 AU · min (p = 0.43). Consistently, ADP-induced PR as a continuous variable was not significantly associated with HALT (p = 0.75). Oral anticoagulation was associated with reduced rates of HALT (odds ratio: 0.41; 95% CI: 0.18 to 0.96; p = 0.04).
Conclusions On-clopidogrel ADP-induced PR was not significantly associated with the occurrence of HALT. In contrast, oral anticoagulation was associated with reduced rates of HALT.
↵∗ Drs. Stratz and Ruile have contributed equally to this work.
This trial was supported by the University Heart Center Freiburg-Bad Krozingen.
Dr. Hochholzer has received consulting and lecture fees from AstraZeneca, Boehringer-Ingelheim, Daiichi-Sankyo, and The Medicines Company. Dr. Stratz has received lecture fees or travel expense from Eli Lilly, Daiichi-Sankyo, and Bayer. Dr. Trenk has received consulting and lecture fees from Amgen, AstraZeneca, Bayer, Berlin Chemie, Bristol-Myers Squibb/Pfizer, Boehringer-Ingelheim, Daiichi Sankyo, and Sanofi. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 29, 2018.
- Revision received August 9, 2018.
- Accepted August 13, 2018.
- 2019 American College of Cardiology Foundation