Key result
Non-vitamin K antagonist oral anticoagulants showed no significant difference in all-cause mortality compared to vitamin K antagonists after transcatheter aortic valve replacement (RR 0.82).
Why the study?
Existing evidence and major society guidelines on the use of NOACs after TAVR are inconclusive and contradictory.
Do non-vitamin K antagonist oral anticoagulants reduce all-cause mortality and complications compared to vitamin K antagonists in patients undergoing transcatheter aortic valve replacement?
Meta-Analysis (n=51,746)
Do non-vitamin K antagonist oral anticoagulants reduce all-cause mortality and complications compared to vitamin K antagonists in patients undergoing transcatheter aortic valve replacement?
Relative Risk: 0.82 (95% CI 0.61–1.1)
Absolute Event Rate: 14.14% vs 20.28%
p-value: p=0.18
NOACs are non-inferior to VKAs for all-cause mortality and major bleeding post-TAVR, while offering a significantly lower risk of intracranial hemorrhage.
NOACs non-inferior to VKAs post-TAVR with lower ICH; extends mixed evidence but dedicated RCTs needed before practice change.
The existing evidence on the use of non-vitamin K oral anticoagulants (NOACs) after transcatheter aortic valve replacement (TAVR) surgery is inconclusive and contradictory. Likewise, major society guidelines remain ambivalent about NOAC use around the time of TAVR. The objective of our meta-analysis was to assess the efficacy of NOACs in comparison to vitamin K antagonists (VKAs) in lowering complications following TAVR. An electronic literature search was conducted using MEDLINE, EMBASE, the international clinical trials database, and Cochrane Library. The primary endpoint was all-cause mortality, and the secondary endpoints included cardiovascular-related death, myocardial infarction, all-cause stroke, and various bleeding events. Forest plots were constructed for the pooled analysis of data. Subgroup and sensitivity analyses were also performed. No significant difference was noted between the NOAC and VKA groups with respect to the risk of all-cause mortality (14.14% vs. 20.28%; risk ratio (RR): 0.82; 95% confidence interval (CI): 0.61 to 1.10; p = 0.18), cardiovascular-related deaths (6.10% vs. 8.55%; RR: 1.02; 95% CI: 0.78 to 1.33; p = 0.91), myocardial infarction (1.52% vs. 2.51%; RR: 1.13; 95% CI: 0.50 to 2.56; p = 0.77), all-cause stroke (2.74% vs. 2.68%; RR: 1.02; 95% CI: 0.75 to 1.39; p = 0.89), major bleeding (7.74% vs. 9.62%; RR: 0.97; 95% CI: 0.58 to 1.61; p = 0.90), minor clinically relevant bleeding (14.33% vs. 13.73%; RR: 0.91; 95% CI: 0.67 to 1.24; p = 0.55), and other bleeding events. The risk of intracranial hemorrhage was lower in the NOAC group than in the VKA group (0.45% vs. 0.67%; RR: 0.61; 95% CI: 0.42 to 0.88; p = 0.008). Our study found NOACs to be non-inferior to VKAs in several outcomes, such as all-cause mortality, cardiovascular-related deaths, myocardial infarction, all-cause stroke, and bleeding events. In fact, NOACs were favored over VKAs, as the VKA group had a higher risk of developing intracranial hemorrhage.
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Goyal et al. (2024) conducted a meta-analysis in Transcatheter Aortic Valve Replacement (TAVR) (n=51,746). Non-vitamin K antagonist oral anticoagulants (NOACs) vs. Vitamin K antagonists (VKAs) was evaluated on All-cause mortality (RR 0.82, 95% CI 0.61 to 1.10, p=0.18). Non-vitamin K antagonist oral anticoagulants showed no significant difference in all-cause mortality compared to vitamin K antagonists after transcatheter aortic valve replacement (RR 0.82).
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