Use of novel oral anticoagulants after transcatheter aortic valve replacement is associated with significantly higher mortality and cardiovascular event rates compared with antiplatelet therapy alone, according to a retrospective study published in the Journal of Clinical Medicine.
The study, conducted at a U.S. medical center, analyzed outcomes in 171 patients who underwent transcatheter aortic valve replacement (TAVR) between January 2018 and August 2024. Among these patients, 136 (79.5%) received antiplatelet therapy alone—primarily dual antiplatelet therapy—while 27 (15.8%) received novel oral anticoagulants (NOACs). An additional eight patients (4.7%) received vitamin K antagonists (VKAs) but were excluded from the main analysis due to sample size limitations.
At 30 days post-procedure, mortality was 33% among patients treated with NOAC compared with 12% among those who received antiplatelet therapy. At one year, mortality rates were 41% and 20%, respectively. After applying inverse probability of treatment weighting (IPTW), NOAC use remained significantly associated with both short- and long-term mortality.
Major adverse cardiovascular and cerebrovascular events (MACCE)—defined as death, myocardial infarction, stroke, or transient ischemic attack—were also more frequent in the NOAC group. At 30 days, MACCE occurred in 22% of NOAC-treated patients compared with 8% in the antiplatelet group. At 1 year, MACCE rates were 34% and 17%, respectively. These differences persisted following adjustment for comorbidities and procedural risk factors.
Baseline characteristics differed between treatment groups. Patients in the NOAC group had more complex clinical profiles, includinghigher mean CHA₂DS₂-VASc scores (4.7 vs 2.0), a greater prevalence of atrial fibrillation (93% vs 13%), and more frequent history of cerebrovascular events (41% vs 10%). Despite adjustments for these differences, outcomes remained worse in the NOAC group.
Major bleeding events occurred in 7% of patients in both the NOAC and antiplatelet groups at 1 year. Minor bleeding was infrequent and did not differ significantly between groups.
NOAC prescribing increased over time, rising from 4% in 2019 to 30% in 2023. However, outcomes did not improve with this shift in prescribing. In subgroup analyses restricted to procedures performed from 2021 to 2024, NOAC use continued to be associated with higher mortality .
The eight patients who received VKAs were described separately. Their survival rate was 87.5% at both 30 days and one year, with no recorded MACCE or major bleeding events. Due to the small sample size, no statistical comparisons were made.
The researchers noted that their findings raise questions about the safety of NOAC use in post-TAVR patients, particularly in patients without clear indications for anticoagulation. In this cohort, antiplatelet therapy, especially dual therapy, was associated with better outcomes. The researchers underscored the need for larger prospective trials to establish optimal antithrombotic strategies after TAVR.
The authors reported no conflicts of interest.
Source: Journal of Clinical Medicine
