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|Issue 141||March 2018|
The report is a product of the VA/HSR&D Evidence Synthesis Program.
Comparing Antithrombotic Strategies after Aortic Valve Replacement
The use of bioprosthetic (containing animal tissue) aortic valves placed surgically – and with a transcatheter approach is a common treatment for valvular heart disease. While most patients are treated with anticoagulant and/or antiplatelet therapy for a period of time after the procedure, the optimal antithrombotic regimen and duration after bioprosthetic aortic valve replacement (bAVR) is unclear, and both guideline recommendations and practice patterns vary significantly. This systematic review sought to summarize the comparative benefits and harms for various anticoagulation strategies following surgical or transcatheter implantation of a bioprosthetic aortic valve, and to determine whether effects differed according to thromboembolic risk profile or concomitant procedure.
Investigators with VA's Evidence-based Synthesis Program (ESP) Center in Portland, OR searched MEDLINE, PubMed, EMBASE, EMB Reviews, and grey literature (unpublished or published in non-commercial form) sources from database inception through January 2017, with a search for new/in-process citations in June 2017. They also examined the bibliographies of relevant articles to identify additional studies. After reviewing more than 4,500 titles and abstracts, ESP investigators included 23 primary studies reported in 22 publications, which included 4 randomized controlled trials (RCTs) and 11 cohort studies that compared antithrombotic strategies in bAVR patients, as well as 3 RCTs and 5 cohort studies assessing various antiplatelet and anticoagulation strategies in patients who have undergone a transcatheter aortic valve replacement (TAVR).
Summary of Findings
There also was insufficient evidence to draw conclusions about the optimal anticoagulation strategy according to thromboembolic risk or receipt of concomitant procedures. In TAVR patients, the strategy of adding a second antiplatelet agent to aspirin for 3 to 6 months had similar effects as aspirin alone on mortality, stroke, and major cardiac events (moderate strength evidence), though use of aspirin alone was associated with a non-significantly lower rate of bleeding (low-strength evidence).
Current Practice and Clinical Outcomes in VA
Implications and Future Research
**A cyberseminar session titled "Comparing Antithrombotic Strategies after Bioprosthetic Aortic Valve Replacement: A Systematic Review" will be held on Monday, May 21 from 1:00pm to 2:00pm (ET). Register for this session.**
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ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.
This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers –; and to disseminate these reports throughout VA.
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