Does a patient with a history of Transcatheter Aortic Valve Implantation (TAVI) on aspirin (acetylsalicylic acid) require additional anticoagulation?

Anticoagulation Management After TAVI

For patients who have undergone TAVI and are currently on aspirin only, dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel should be considered for the first 3-6 months after the procedure, followed by lifelong single antiplatelet therapy if there are no other indications for oral anticoagulation. 1

Standard Antithrombotic Regimen After TAVI

• Dual antiplatelet therapy with aspirin (75-100 mg daily) and clopidogrel (75 mg daily) is recommended for the first 3-6 months after TAVI in patients without other indications for oral anticoagulation 1
• After the initial 3-6 month period, patients should continue lifelong single antiplatelet therapy (typically aspirin) 1
• For patients at high bleeding risk, single antiplatelet therapy alone may be considered immediately after TAVI 1

Recent Evidence Supporting Single Antiplatelet Therapy

• The POPular TAVI trial demonstrated that aspirin alone compared to aspirin plus clopidogrel resulted in significantly less bleeding events (15.1% vs 26.6%) without an increase in thromboembolic events 2
• This trial showed that aspirin monotherapy was superior to DAPT for the composite endpoint of bleeding or thromboembolic events at 1 year 2
• Based on this evidence, single antiplatelet therapy may be reasonable in patients with higher bleeding risk 1

Special Considerations

Patients with Indications for Oral Anticoagulation

• If the patient has other indications for oral anticoagulation (such as atrial fibrillation, venous thromboembolism, or severely impaired LV function with EF <35%), lifelong oral anticoagulation is recommended 1
• For patients with mechanical valve prostheses, anticoagulation with a vitamin K antagonist (VKA) is recommended lifelong with a target INR based on the specific valve type and position 1
• NOACs (non-vitamin K antagonist oral anticoagulants) are contraindicated in patients with mechanical valve prostheses 1

Timing Considerations

• If the TAVI procedure was performed within the past 3-6 months and the patient is only on aspirin, adding clopidogrel should be considered to complete the recommended dual antiplatelet therapy period 1
• If the TAVI procedure was performed more than 6 months ago, continuing single antiplatelet therapy with aspirin alone is appropriate 1

Risk Assessment

• Bleeding risk should be carefully assessed when determining the optimal antithrombotic regimen 1
• Patients with high bleeding risk may benefit from single antiplatelet therapy rather than DAPT 1, 2
• Factors that increase bleeding risk include advanced age, prior bleeding, renal impairment, liver disease, and concomitant use of medications that increase bleeding risk 1

Common Pitfalls and Caveats

• Avoid using oral anticoagulation with VKA for the first 3 months after TAVI unless there are specific indications for anticoagulation 1
• Rivaroxaban (10 mg daily) plus aspirin is contraindicated after bioprosthetic TAVI in the absence of other indications for oral anticoagulants 1
• Do not use prasugrel or ticagrelor as part of triple therapy if anticoagulation is required 1
• In patients requiring anticoagulation plus antiplatelet therapy, the INR should be kept in the lower part of the recommended target range to reduce bleeding risk 1
• Regular monitoring for both thrombotic and bleeding complications is essential, especially during the first year after TAVI 1