Author + information
- Received March 1, 2019
- Revision received May 29, 2019
- Accepted June 4, 2019
- Published online August 19, 2019.
- Ioanna Kosmidou, MD, PhDa,b,∗ (, )@IKosmidou@crfheart,
- Yangbo Liu, MSa,
- Maria C. Alu, MSb,
- Mengdan Liu, MSa,
- Mahesh Madhavan, MDa,b,
- Tarun Chakravarty, MDc,
- Raj Makkar, MDc,
- Vinod H. Thourani, MDd,
- Angelo Biviano, MD, MPHb,
- Susheel Kodali, MDa,b and
- Martin B. Leon, MDa,b
- aClinical Trials Center, Cardiovascular Research Foundation, New York, New York
- bDepartment of Medicine, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
- cDepartment of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
- dDepartment of Cardiac Surgery, Medstar Heart and Vascular Institute/Georgetown University, Washington, DC
- ↵∗Address for correspondence:
Dr. Ioanna Kosmidou, Columbia University Medical Center, Department of Cardiology, Herbert Irving Pavillion-6, New York, New York 10032.
Objectives The study sought to determine the patterns of antithrombotic therapy and association with clinical outcomes in patients with atrial fibrillation (AF) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65–74 years, sex category) score ≥2 following transcatheter aortic valve replacement (TAVR).
Background The impact of antithrombotic regimens on clinical outcomes in patients with AF and severe aortic stenosis treated with TAVR is unknown.
Methods In the randomized PARTNER II (Placement of Aortic Transcatheter Valve II) trial and associated registries, 1,621 patients with prior AF and CHA2DS2-VASc score ≥2 comprised the study cohort. Outcomes were analyzed according to antithrombotic therapy.
Results During the 5-year enrollment period, 933 (57.6%) patients were discharged on oral anticoagulant therapy (OAC). Uninterrupted antiplatelet therapy (APT) for at least 6 months or until an endpoint event was used in 544 of 933 (58.3%) of patients on OAC and 77.5% of patients not on OAC. At 2 years, patients on OAC had a similar rate of stroke (6.6% vs. 5.6%; p = 0.53) and the composite outcome of death or stroke (29.7% vs. 31.8%; p = 0.33), compared with no OAC. OAC with APT was associated with a reduced rate of stroke (5.4% vs. 11.1%; p = 0.03) and death or stroke (29.7% vs. 40.1%; p = 0.01), compared with no OAC or APT. Following adjustment, OAC with APT and APT alone were both associated with reduced rates of stroke compared with no OAC or APT (hazard ratio for OAC+APT: 0.43, 95% confidence interval: 0.22 to 0.85; p = 0.015; hazard ratio for APT alone: 0.32, 95% confidence interval: 0.16 to 0.65; p = 0.002), while OAC alone was not.
Conclusions Among patients with prior AF undergoing TAVR, antiplatelet with or without anticoagulant therapy was associated with a reduced risk of stroke at 2 years, implicating multifactorial stroke mechanisms in this population.
- antithrombotic therapy
- aortic stenosis
- atrial fibrillation
- clinical outcomes
- transcatheter aortic valve replacement
The PARTNER II (Placement of Aortic Transcatheter Valve II) trial was funded by Edwards Lifesciences (Santa Clara, California). Ms. Alu has received consulting fees from Cardiac Dimensions. Dr. Makkar has received grants from Edwards Lifesciences and St. Jude Medical; has received consulting fees from Abbott Vascular, Cordis, and Medtronic; and holds equity in Entourage Medical. Dr. Thourani has served on advisory board for Edwards Lifesciences, Abbott Vascular, Gore Vascular, Bard Medical, JenaValve, and Boston Scientific. Dr. Kodali has received consulting fees from Edwards Lifesciences, Medtronic, Claret Medical, Merrill Lifesciences, BioTrace Medical, and Microinterventional Devices; has served on advisory boards for Thubrikar Aortic Valve, Dura Biotech, Abbott Vascular, Paieon Medical, and St. Jude Medical; and owns equity in Thubrikar Aortic Valve, Dura Biotech, BioTrace Medical, and Microinterventional Devices. Dr. Leon has received Institutional Research Support from Boston Scientific, Edwards, and Medtronic; and has served on the PARTNER Trial Executive Committee (no direct compensation). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 1, 2019.
- Revision received May 29, 2019.
- Accepted June 4, 2019.
- 2019 American College of Cardiology Foundation
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