Antiplatelet Therapy versus Anticoagulation after Surgical Bioprosthetic Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Kevin R. An; Emilie P. Belley-Cote; Kevin J. Um; Saurabh Gupta; Graham R. McClure; Iqbal H. Jaffer; Arjun Pandey; Jessica Spence; Sake J. Van der Wall; John W. Eikelboom; Richard P. Whitlock

doi:10.1055/s-0038-1676816

Thrombosis and Haemostasis, Inhaltsverzeichnis

Thromb Haemost 2019; 119(02): 328-339
DOI: 10.1055/s-0038-1676816

Stroke, Systemic or Venous Thromboembolism

Georg Thieme Verlag KG Stuttgart · New York

Antiplatelet Therapy versus Anticoagulation after Surgical Bioprosthetic Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Kevin R. An

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada

,

Emilie P. Belley-Cote

²Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

³Division of Cardiology, McMaster University, Hamilton, Ontario, Canada

⁴Population Health Research Institute, Hamilton, Ontario, Canada

,

Kevin J. Um

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada

,

Saurabh Gupta

²Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

⁵Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada

,

Graham R. McClure

¹Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada

,

Iqbal H. Jaffer

²Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

⁴Population Health Research Institute, Hamilton, Ontario, Canada

⁵Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada

,

Arjun Pandey

⁶Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada

,

Jessica Spence

²Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

⁷Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada

,

Sake J. Van der Wall

⁸Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden University, Leiden, The Netherlands

,

John W. Eikelboom

⁴Population Health Research Institute, Hamilton, Ontario, Canada

⁹Division of Hematology and Thromboembolism, McMaster University, Hamilton, Ontario, Canada

,

Richard P. Whitlock

²Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

⁴Population Health Research Institute, Hamilton, Ontario, Canada

⁵Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada

› Institutsangaben

Abstract

Background The optimal antithrombotic therapy after surgical bioprosthetic aortic valve replacement (BAVR) is uncertain. We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) comparing antiplatelet therapy and anticoagulation in patients with surgical BAVR.

Methods We searched Cochrane CENTRAL, MEDLINE and EMBASE from inception to 3 November 2017 for studies evaluating antiplatelet therapy versus anticoagulation early after surgical BAVR. We performed title and abstract screening, full-text review, risk of bias evaluation and data collection independently and in duplicate. We evaluated overall quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework, and pooled data using a random effects model.

Results We identified 2 RCTs (n = 397) and 5 observational studies (n = 2,012) meeting our eligibility criteria. The mean follow-up for all outcomes was 3 months in RCTs, and 10 months for observational studies. Antiplatelet compared with anticoagulant therapy demonstrated a trend towards fewer major bleeds in RCTs (relative risk [RR], 0.34; 95% confidence interval [CI], 0.11–1.04, p = 0.06, I ² = 0%, low quality evidence), and significantly fewer major bleeds in observational studies (RR, 0.34; 95% CI, 0.20–0.58, p ≤ 0.0001, I ² = 0%, very low quality evidence), but stroke, thromboembolism and mortality did not show a significant difference in either RCTs or observational studies.

Conclusion Antiplatelet therapy demonstrated reduced bleeding risk with no negative effects on stroke, thromboembolism or mortality compared with anticoagulation therapy after surgical BAVR. Our confidence in the results is reduced by the low quality of the available evidence.

Keywords

aspirin - warfarin - VKA - antithrombotic therapy - biological aortic valve replacement

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Referenzen

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