Safety and Use of Anticoagulation After Aortic Valve Replacement With Bioprostheses: A Meta-Analysis.
Abstract
BACKGROUND: The American College of Cardiology guidelines recommend 3 months of anticoagulation
after replacement of the aortic valve with a bioprosthesis. However, there remains
great variability in the current clinical practice and conflicting results from clinical
studies. To assist clinical decision making, we pooled the existing evidence to assess
whether anticoagulation in the setting of a new bioprosthesis was associated with
improved outcomes or greater risk of bleeding. METHODS AND RESULTS: We searched the
PubMed database from the inception of these databases until April 2015 to identify
original studies (observational studies or clinical trials) that assessed anticoagulation
with warfarin in comparison with either aspirin or no antiplatelet or anticoagulant
therapy. We included the studies if their outcomes included thromboembolism or stroke/transient
ischemic attacks and bleeding events. Quality assessment was performed in accordance
with the Newland Ottawa Scale, and random effects analysis was used to pool the data
from the available studies. I(2) testing was done to assess the heterogeneity of the
included studies. After screening through 170 articles, a total of 13 studies (cases=6431;
controls=18210) were included in the final analyses. The use of warfarin was associated
with a significantly increased risk of overall bleeding (odds ratio, 1.96; 95% confidence
interval, 1.25-3.08; P<0.0001) or bleeding risk at 3 months (odds ratio, 1.92; 95%
confidence interval, 1.10-3.34; P<0.0001) compared with aspirin or placebo. With regard
to composite primary outcome variables (risk of venous thromboembolism, stroke, or
transient ischemic attack) at 3 months, no significant difference was seen with warfarin
(odds ratio, 1.13; 95% confidence interval, 0.82-1.56; P=0.67). Moreover, anticoagulation
was also not shown to improve outcomes at time interval >3 months (odds ratio, 1.12;
95% confidence interval, 0.80-1.58; P=0.79). CONCLUSIONS: Contrary to the current
guidelines, a meta-analysis of previous studies suggests that anticoagulation in the
setting of an aortic bioprosthesis significantly increases bleeding risk without a
favorable effect on thromboembolic events. Larger, randomized controlled studies should
be performed to further guide this clinical practice.
Type
Journal articleSubject
anticoagulantsbioprosthesis
meta-analysis
platelet aggregation inhibitors
surgical aortic valve replacement
transcatheter aortic valve replacement
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https://hdl.handle.net/10161/12516Published Version (Please cite this version)
10.1161/CIRCOUTCOMES.115.002696Publication Info
Riaz, Haris; Alansari, Shehab Ahmad Redha; Khan, Muhammad Shahzeb; Riaz, Talha; Raza,
Sajjad; Luni, Faraz Khan; ... Krasuski, Richard A (2016). Safety and Use of Anticoagulation After Aortic Valve Replacement With Bioprostheses:
A Meta-Analysis. Circ Cardiovasc Qual Outcomes, 9(3). pp. 294-302. 10.1161/CIRCOUTCOMES.115.002696. Retrieved from https://hdl.handle.net/10161/12516.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Richard Andrew Krasuski
Professor of Medicine
Dr. Richard Krasuski is Director of the Adult Congenital Heart Center at Duke University
Medical Center, the Director of Hemodynamic Research, and the Medical Director of
the CTEPH Program. He is considered a thought leader in the fields of pulmonary hypertension
and congenital heart disease. His research focus is in epidemiologic and clinical
studies involving patients with pulmonary hypertension and patients with congenital
heart disease. He is involved in multiple multicenter studies thr

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