What anticoagulation is recommended for an 89-year-old male with Transcatheter Aortic Valve Replacement (TAVR) and atrial fibrillation (a fib) on Plavix (clopidogrel)?

Anticoagulation Management for 89-Year-Old Male with TAVR and Atrial Fibrillation on Plavix

For an 89-year-old male with TAVR and atrial fibrillation who is currently on Plavix (clopidogrel), oral anticoagulation with a direct oral anticoagulant (DOAC) alone is recommended, with discontinuation of Plavix unless there are specific recent coronary or cerebrovascular indications.

Assessment of Thrombotic and Bleeding Risks

Thrombotic Risk Factors:

• Advanced age (89 years) - significant risk factor for stroke
• Atrial fibrillation - increases stroke risk 3-4 fold
• TAVR - bioprosthetic valve increases thromboembolic risk

Anticoagulation Decision Algorithm:

1. Determine CHA₂DS₂-VASc score:

   • Age ≥75 years: 2 points
   • Atrial fibrillation: requires anticoagulation assessment
   • This patient has at minimum a CHA₂DS₂-VASc score of 2 (likely higher with additional comorbidities)

2. Evaluate current antithrombotic regimen:

   • Currently on Plavix (clopidogrel) - likely prescribed post-TAVR
   • No current oral anticoagulation despite AF

Evidence-Based Recommendations

For Atrial Fibrillation:

• The 2014 AHA/ACC guidelines recommend oral anticoagulation for patients with nonvalvular AF with a CHA₂DS₂-VASc score of 2 or greater 1
• Options include warfarin (INR 2.0-3.0) or a direct oral anticoagulant (DOAC) such as dabigatran, rivaroxaban, or apixaban 1

For TAVR:

• The 2014 AHA/ACC guideline for valvular heart disease states: "Clopidogrel 75 mg daily may be reasonable for the first 6 months after TAVR in addition to life-long aspirin 75 mg to 100 mg daily" (Class IIb, Level of Evidence C) 1
• However, this recommendation is for patients without other indications for anticoagulation

For Combined TAVR and AF:

• For patients with indications for long-term oral anticoagulation (such as AF), the adjunctive use of antiplatelet therapy increases bleeding risk 2
• The 2020 ACC Expert Consensus recommends that for patients on oral anticoagulation for AF who have undergone PCI >12 months ago, antiplatelet therapy may be stopped and most patients can be treated with an oral anticoagulant alone 1

Specific Management Recommendation

1. Discontinue Plavix (clopidogrel) unless:

   • TAVR was performed within the last 6 months
   • Recent acute coronary syndrome within 12 months
   • Recent stroke or TIA within 3 months

2. Initiate oral anticoagulation:

   • Preferred: DOAC (apixaban, dabigatran, or rivaroxaban) due to:

     • Lower risk of intracranial hemorrhage compared to warfarin 3
     • No need for regular INR monitoring
     • Better safety profile in elderly patients

   • If DOAC contraindicated (mechanical valve, severe renal impairment):

     • Warfarin with target INR 2.0-3.0 4

3. Dosing considerations for elderly patient:

   • For apixaban: Consider reduced dose (2.5mg BID) if ≥2 of: age ≥80 years, body weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 3
   • For other DOACs: Adjust based on renal function and bleeding risk

Important Caveats and Monitoring

• Avoid triple therapy (DOAC + aspirin + clopidogrel) due to excessive bleeding risk in elderly patients 1
• Monitor for bleeding complications closely, especially GI and intracranial bleeding
• Assess renal function before initiating DOAC and periodically thereafter
• Evaluate for drug interactions with current medications
• Regular follow-up every 3-6 months to assess medication adherence and complications

Special Considerations

• If the patient has had a recent coronary intervention (<6 months), consider continuing a single antiplatelet agent with oral anticoagulation, with preference for clopidogrel over aspirin 1
• If the patient has a mechanical heart valve (unlikely with TAVR), warfarin is required instead of a DOAC 1

This approach balances the need for stroke prevention in atrial fibrillation while minimizing bleeding risk in this elderly patient with multiple risk factors.