What is the recommended duration of dual anti-platelet therapy (DAPT) after Transcatheter Aortic Valve Replacement (TAVR)?

Duration of Dual Antiplatelet Therapy After TAVR

The recommended duration of dual antiplatelet therapy (DAPT) after Transcatheter Aortic Valve Replacement (TAVR) is 3-6 months with aspirin 75-100 mg daily lifelong and clopidogrel 75 mg daily for the initial period. 1, 2

Standard Antithrombotic Regimen Post-TAVR

• For patients without an indication for anticoagulation, DAPT consisting of aspirin 75-100 mg daily lifelong and clopidogrel 75 mg daily for 3-6 months is the standard recommendation 1, 2
• Low-dose aspirin (75-100 mg daily) is preferred over higher doses to minimize bleeding risk while maintaining efficacy 1
• After completion of the DAPT period, patients should continue aspirin 75-100 mg daily lifelong 1, 2

Evidence Challenging Standard DAPT Duration

• Recent network meta-analyses suggest that single antiplatelet therapy (SAPT) with aspirin alone may have lower bleeding rates without increasing stroke or mortality compared to either 3-month or 6-month DAPT regimens 3, 4
• DAPT appears to significantly increase the risk of major or life-threatening bleeding compared to SAPT (RR=1.67,95% CI 1.24-2.24) 4
• Some evidence suggests clopidogrel monotherapy might be associated with lower cardiovascular mortality compared to aspirin monotherapy during 2-year follow-up after TAVR 5

Special Populations

• For patients with pre-existing atrial fibrillation or other indications for oral anticoagulation:
  • Vitamin K antagonist therapy with a target INR of 2.0-2.5 is recommended for the first 3 months post-TAVR 1, 2
  • After 3 months, patients may transition to a direct oral anticoagulant (DOAC) if they have a long-term indication for anticoagulation 2
  • Adding antiplatelet therapy to anticoagulation increases bleeding risk 2-3 fold, so the indication for anticoagulation should be carefully assessed 1

Monitoring Recommendations

• Echocardiography should be performed at 30 days post-TAVR and then annually 2
• ECG monitoring is recommended at 30 days and annually to detect asymptomatic atrial fibrillation or conduction defects 1, 2
• Regular assessment for bleeding complications is essential, particularly during the period of DAPT 2

Clinical Decision Algorithm

1. For standard TAVR patients without other indications for anticoagulation:

   • Prescribe aspirin 75-100 mg daily (lifelong) plus clopidogrel 75 mg daily for 3-6 months 1, 2
   • Consider shorter DAPT duration (3 months) in patients with higher bleeding risk 3

2. For TAVR patients with atrial fibrillation or other indications for anticoagulation:

   • Prescribe warfarin with target INR 2.0-2.5 for the first 3 months 1, 2
   • Consider adding aspirin 75-100 mg daily only in patients at high thrombotic risk and low bleeding risk 1
   • After 3 months, transition to appropriate long-term anticoagulation strategy based on indication 2

3. For all patients:

   • Monitor for bleeding complications, especially during DAPT period 2, 4
   • Schedule echocardiography at 30 days and annually 1, 2
   • Perform ECG at 30 days and annually 1, 2

While the current guidelines still recommend DAPT for 3-6 months, emerging evidence suggests that SAPT may provide similar protection against thrombotic events with lower bleeding risk. Future guideline updates may modify these recommendations as more evidence becomes available.