How long should aspirin be continued after transcatheter aortic valve implantation (TAVI)?

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Duration of Aspirin After TAVI

Aspirin should be continued lifelong after TAVI in patients without an indication for oral anticoagulation. 1

Primary Recommendation

  • Aspirin 75-100 mg daily is recommended indefinitely after TAVI for all patients who do not have another indication for oral anticoagulation (such as atrial fibrillation). 1

  • This represents a Class IIa recommendation with Level B-R evidence from both ACC/AHA and ESC/EACTS guidelines, making it the consensus standard of care. 1

Key Evidence Supporting Lifelong Single Antiplatelet Therapy

The shift away from dual antiplatelet therapy (DAPT) to aspirin monotherapy is supported by robust randomized trial data:

  • The POPular TAVI trial (2020) demonstrated that aspirin alone significantly reduced all bleeding events (15.1% vs 26.6%, P=0.001) and non-procedure-related bleeding (15.1% vs 24.9%, P=0.005) compared to aspirin plus clopidogrel over 12 months. 2

  • Critically, aspirin monotherapy did not increase thromboembolic events—the composite of cardiovascular death, ischemic stroke, or myocardial infarction was identical between groups (9.7% vs 9.9%). 2

  • A 2021 patient-level meta-analysis of 1,086 patients across 4 randomized trials confirmed that aspirin alone reduced the composite of mortality, bleeding, stroke, or MI at both 30 days (10.3% vs 14.7%, P=0.034) and 3 months (11.0% vs 16.5%, P=0.02) compared to DAPT. 3

  • An additional meta-analysis of 4,805 patients showed aspirin alone reduced all-cause bleeding (OR 0.41, P<0.00001), major vascular bleeding (OR 0.51, P=0.001), and transfusion requirements (OR 0.39, P=0.05) without increasing stroke, MI, or mortality. 4

What About Dual Antiplatelet Therapy?

DAPT (aspirin plus clopidogrel) is no longer recommended as routine therapy after TAVI. 1

  • The ACC/AHA guidelines give DAPT only a Class IIb recommendation (may be reasonable) for 3-6 months in patients at low bleeding risk, reflecting weak and outdated evidence. 1

  • Multiple trials have shown DAPT increases bleeding complications without providing ischemic benefit, leading to the ESC/EACTS Class I recommendation for single antiplatelet therapy. 1

Special Circumstances

Patients Already on Oral Anticoagulation

  • If a patient has an independent indication for oral anticoagulation (atrial fibrillation, mechanical valve, venous thromboembolism), continue the oral anticoagulant lifelong and do NOT add aspirin routinely. 1

  • The combination of oral anticoagulation plus antiplatelet therapy significantly increases bleeding risk and should only be considered in specific high-risk scenarios (such as recent acute coronary syndrome). 1

Early Post-Procedural Period

  • Some centers use DAPT for the first 1-3 months post-TAVI based on older practice patterns, but current evidence does not support this approach. 5

  • Starting aspirin alone immediately after TAVI is safe and preferred based on contemporary guidelines. 1

Valve Thrombosis Concerns

  • Subclinical leaflet thrombosis occurs in 10-15% of TAVI patients between 1-3 months post-procedure, but aspirin monotherapy has not been shown to increase this risk compared to DAPT. 6

  • If symptomatic valve thrombosis develops (detected by increased gradients or symptoms), treatment requires oral anticoagulation with warfarin or a DOAC, not intensification of antiplatelet therapy. 6

Common Pitfalls to Avoid

  • Do not automatically prescribe DAPT "just to be safe"—this outdated approach increases bleeding without reducing thrombotic events. 2, 4

  • Do not stop aspirin after 6-12 months thinking the "high-risk period" has passed—lifelong therapy is indicated. 1

  • Do not add clopidogrel to oral anticoagulation in patients with atrial fibrillation unless there is a compelling additional indication (such as recent stent placement). 1

  • Do not use rivaroxaban 10 mg plus aspirin after TAVI—this combination is explicitly contraindicated (Class III: Harm) due to increased bleeding without benefit. 1

Practical Algorithm

  1. At TAVI discharge: Start aspirin 75-100 mg daily. 1

  2. If no indication for oral anticoagulation: Continue aspirin indefinitely. 1

  3. If indication for oral anticoagulation exists: Use oral anticoagulant alone; discontinue aspirin. 1

  4. If bleeding risk is exceptionally low and institutional practice favors DAPT: Consider adding clopidogrel 75 mg for 3 months maximum, then continue aspirin alone lifelong. 1

  5. Monitor for bleeding complications during the first 3 months, as this is when most bleeding events occur. 2

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

6
Research

[Transcatheter aortic valve thrombosis].

Annales de cardiologie et d'angeiologie, 2017

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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