Antithrombotic Therapy and Cardiovascular Outcomes After Transcatheter Aortic Valve Replacement in Patients With Atrial Fibrillation
Antithrombotic Therapy and Cardiovascular Outcomes After Transcatheter Aortic Valve Replacement in Patients With Atrial Fibrillation
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DOI：
10.1016/j.jcin.2019.06.001
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发表时间：
2019-08-26
影响因子：
11.3
通讯作者：
Leon, Martin B.
中科院分区：
文献类型：
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作者：
Kosmidou, Ioanna;Liu, Yangbo;Leon, Martin B.
本研究旨在确定房颤（AF）和CHA（2）DS（2）-VASc患者的抗血栓治疗模式及其与临床结局的关系。（充血性心力衰竭，高血压，年龄>= 75岁，糖尿病，既往中风或短暂性脑缺血发作或血栓栓塞，血管疾病，年龄65-74岁，经导管主动脉瓣置换术（TAVR）后，性别分类）评分>= 2。背景抗血栓治疗方案对AF和重度主动脉瓣狭窄患者接受TAVR治疗的临床结局的影响尚不清楚。（主动脉经导管瓣膜植入II）试验和相关登记研究中，1，621例既往AF和CHA（2）DS（2）-VASc评分>= 2的患者组成了研究队列。根据抗血栓治疗结果进行分析。结果在5年的招募期间，933例（57.6%）患者出院后口服抗凝治疗（OAC）。933例接受OAC治疗的患者中有544例（58.3%）和77.5%的未接受OAC治疗的患者接受了至少6个月或直至发生终点事件的不间断抗血小板治疗（APT）。2年时，接受OAC治疗的患者与未接受OAC治疗的患者相比，卒中发生率相似（6.6% vs. 5.6%; p = 0.53），死亡或卒中的复合结局相似（29.7% vs. 31.8%; p = 0.33）。与未使用OAC或APT相比，使用APT的OAC与卒中发生率降低（5.4% vs. 11.1%; p = 0.03）和死亡或卒中发生率降低（29.7% vs. 40.1%; p = 0.01）相关。调整后，与不使用OAC或APT相比，OAC联合APT和单独使用APT均与卒中发生率降低相关（OAC+APT的风险比：0.43，95%置信区间：0.22至0.85; p = 0.015;单独APT的风险比：0.32，95%置信区间：0.16至0.65; p = 0.002），而OAC单用则不然。结论：在接受TAVR的既往AF患者中，抗血小板联合或不联合抗凝治疗与2年时卒中风险降低相关，表明该人群中存在多因素卒中机制。(c)2019年由美国心脏病学会基金会。
OBJECTIVES The study sought to determine the patterns of antithrombotic therapy and association with clinical outcomes in patients with atrial fibrillation (AF) and CHA(2)DS(2)-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 CHA(2)DS(2)-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. (c) 2019 by the American College of Cardiology Foundation.