What is the pharmacologic management for coronary artery disease post-Transcatheter Aortic Valve Replacement (TAVR)?

Pharmacologic Management of Coronary Artery Disease Post-TAVR

For patients with coronary artery disease after TAVR, the recommended antithrombotic regimen is aspirin 75-100 mg daily lifelong, with clopidogrel 75 mg daily for 3-6 months, while continuing to manage underlying coronary disease with appropriate medical therapy. 1

Antithrombotic Therapy Post-TAVR

Standard Approach for Patients with CAD Post-TAVR:

• Baseline (all patients):
  • Aspirin 75-100 mg daily lifelong 1
  • Clopidogrel 75 mg daily for 3-6 months 1

Special Considerations:

1. Patients with atrial fibrillation or high risk of venous thromboembolism:

   • Consider warfarin (INR 2.0-2.5) instead of dual antiplatelet therapy 1
   • NOACs (direct thrombin inhibitors or anti-Xa agents) are contraindicated in patients with mechanical valves 1

2. Patients with high bleeding risk:

   • Single antiplatelet therapy with aspirin alone may be considered 1
   • Recent evidence suggests aspirin alone decreases bleeding risk without increasing stroke or mortality compared to DAPT 2, 3

3. Patients with recent acute coronary syndrome or high ischemic risk:

   • Triple therapy (aspirin, clopidogrel, and VKA) may be considered for 1-6 months 1
   • When using triple therapy, target INR should be in the lower part of the recommended range 1

Management of Underlying Coronary Disease

Approximately 60-75% of TAVR patients have concomitant CAD 4, requiring comprehensive management:

Medical Therapy:

• Anti-ischemic medications:

  • Beta-blockers for patients with prior MI or reduced ejection fraction
  • Nitrates for symptomatic angina
  • Calcium channel blockers for angina when beta-blockers are contraindicated

• Risk factor modification:

  • Lipid-lowering therapy (statins)
  • Blood pressure control (target <130/80 mmHg)
  • Diabetes management
  • Smoking cessation

Revascularization Considerations:

• Complete revascularization before TAVR should be considered for patients with extensive, proximal, and severe CAD (residual SYNTAX score <8) 4
• PCI timing relative to TAVR:
  1. Before TAVR: Preferred for stable patients with complex lesions
  2. Combined with TAVR: Consider for unstable patients with simple lesions or when risk of coronary occlusion exists
  3. After TAVR: For patients who remain symptomatic despite optimal medical therapy

Follow-up Protocol

1. 30-day follow-up with TAVR team:

   • Echocardiography to assess valve function
   • ECG to monitor for conduction abnormalities
   • Evaluate coronary symptoms

2. 3-month follow-up with primary care or geriatrician:

   • Medication reconciliation
   • Assessment of functional status
   • Monitor for bleeding complications from antithrombotic therapy

3. 6-month follow-up with primary cardiologist:

   • Consider discontinuation of clopidogrel if completed 3-6 month course
   • Reassess angina symptoms and need for anti-ischemic medication adjustment
   • ECG if symptoms warrant

4. Annual follow-up:

   • Echocardiography to monitor valve function
   • ECG to assess for arrhythmias
   • Reassessment of coronary symptoms and optimization of medical therapy

Important Caveats and Pitfalls

• Bleeding risk: DAPT increases bleeding risk compared to aspirin alone, particularly in elderly TAVR patients 2, 3
• Medication adherence: Critical to emphasize the importance of antiplatelet therapy adherence
• Drug interactions: Monitor for interactions between antiplatelets and other medications
• Dental procedures: Maintain optimal dental hygiene and follow antibiotic prophylaxis guidelines 1
• Avoid NOACs: Direct thrombin inhibitors or anti-Xa agents should not be used in patients with mechanical valves and are not recommended for bioprosthetic valves post-TAVR 1

The management of CAD post-TAVR requires careful coordination between the TAVR team, primary cardiologist, and primary care physician to ensure optimal outcomes and minimize complications from both the valve procedure and underlying coronary disease.