What is the role of Plavix (clopidogrel) after aortic valve replacement (AVR)?

From the Guidelines

Plavix (clopidogrel) may be considered for the first 3 to 6 months after transcatheter aortic valve replacement (TAVR) in addition to lifelong aspirin 75 mg to 100 mg daily, especially in patients at low risk of bleeding. This recommendation is based on the most recent guidelines, including the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1. The use of dual-antiplatelet therapy with aspirin and clopidogrel for 3 to 6 months after TAVR may be reasonable in patients at low risk of bleeding, as stated in the guideline 1.

Key Considerations

• The decision to use Plavix after TAVR should be made by the cardiac surgeon and cardiologist based on the patient's specific clinical situation, type of valve implanted, and other cardiovascular risk factors.
• Antiplatelet and anticoagulation therapy after valve replacement is crucial to prevent thromboembolic complications while balancing the risk of bleeding.
• The medication regimen should be carefully tailored to each patient's needs, taking into account their individual risk factors and medical history.

Relevant Guidelines

• The 2020 ACC/AHA guideline for the management of patients with valvular heart disease recommends dual-antiplatelet therapy with aspirin and clopidogrel for 3 to 6 months after TAVR in patients at low risk of bleeding 1.
• The 2017 ACC expert consensus decision pathway for TAVR also supports the use of antithrombotic therapy, including clopidogrel, after TAVR 1.
• The 2014 AHA/ACC guideline for the management of patients with valvular heart disease recommends clopidogrel 75 mg daily for the first 6 months after TAVR in addition to lifelong aspirin 75 mg to 100 mg daily 1.

Clinical Evidence

• Studies have shown that valve thrombosis may develop in patients after TAVR, and the use of anticoagulation therapy, such as warfarin, may be beneficial in preventing this complication 1.
• However, the use of Plavix after TAVR is not universally recommended and should be individualized based on the patient's specific clinical situation and risk factors.

From the Research

Antithrombotic Therapy After Aortic Valve Replacement (AVR)

The use of antithrombotic therapy, including Plavix (clopidogrel), after aortic valve replacement (AVR) is a topic of ongoing research and debate.

• The optimal antithrombotic regimen and duration of therapy following AVR or transcatheter aortic valve implantation (TAVI) are not yet fully defined 2.
• Current practice guidelines recommend dual antiplatelet therapy (DAPT) following TAVI using a combination of low-dose aspirin and clopidogrel for 3-6 months 2.
• However, recent studies have reported better outcomes with single antiplatelet therapy than with dual antiplatelet therapy in the occurrence of bleeding events, while not increasing thrombotic events 3, 4.

Comparison of Aspirin and Clopidogrel

• A study comparing aspirin and clopidogrel as single antithrombotic therapy after TAVR found that clopidogrel monotherapy was associated with a lower incidence of cardiovascular death compared with aspirin monotherapy during the 2-year follow-up after TAVR, regardless of anticoagulation use 3.
• Another study found that aspirin plus clopidogrel (dual antiplatelet therapy) tended to occur more frequently than aspirin alone (single antiplatelet therapy) in the composite of death, myocardial infarction, stroke or transient ischemic attack, or major or life-threatening bleeding within the 3 months following TAVR 4.

Anticoagulation Therapy

• A meta-analysis comparing oral anticoagulants (OAC) alone versus OAC with antiplatelet therapy (APT) following TAVR in patients with atrial fibrillation found that OAC with APT increased the risk of bleeding compared to OAC alone without decreasing the risk of stroke 5.
• A study on antiplatelet therapy early after bioprosthetic aortic valve replacement found that administration of aspirin confers no advantage compared to no antiplatelet therapy in patients without thromboembolic risk factors 6.

Plavix (Clopidogrel) After AVR

• There is limited direct evidence on the use of Plavix (clopidogrel) after AVR.
• However, studies on dual antiplatelet therapy (DAPT) using clopidogrel and aspirin suggest that DAPT may not be necessary for all patients after TAVR, and that single antiplatelet therapy may be sufficient in some cases 3, 4.