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POPular TAVI Reveals No Need for Clopidogrel in Afib Patients Undergoing TAVR

In This Article

  • The POPular TAVI trial shows that atrial fibrillation patients undergoing TAVR have lower mortality rates and bleed less when administered oral anticoagulation (OAC) alone than in combination with clopidogrel
  • The trial also shows an increase in ischemic events in the clopidogrel arm, pointing to an elevated adverse impact on patients' clinical outcomes
  • The results of this trial support the practice of not administering clopidogrel to patients who have an indication for OAC

About 30% of patients undergoing transcatheter aortic valve replacement (TAVR) have atrial fibrillation (Afib) and require chronic oral anticoagulation (OAC) to reduce their risk of stroke and thromboembolism. Current practice guidelines on antithrombotic treatments in patients who have an indication for anticoagulation after transcatheter aortic valve implantation (TAVI) suggest a vitamin K antagonist either alone or in combination with aspirin or clopidogrel. A recent study found that, in those patients, adding three months of clopidogrel to the antithrombotic regimen after the procedure does not appear to have any benefit.

The POPular TAVI trial, reported during the virtual American College of Cardiology (ACC) 2020 Scientific Sessions, showed that patients who received clopidogrel in addition to their OAC regimen bled more and had higher mortality rates through one year of follow-up. These results indicate that in patients who have an established indication for oral anticoagulants—mostly Afib—undergoing TAVR, oral anticoagulant alone has better outcomes than oral anticoagulants plus clopidogrel. The findings, published in the New England Journal of Medicine, also show that the use of oral anticoagulants alone does not increase the number of thrombotic events as compared to a clopidogrel-combined therapy.

Sammy Elmariah, MD, MPH, director of Interventional Cardiology Research in the Corrigan Minehan Heart Center at Massachusetts General Hospital, says one of the more informative pieces of the study was its look at secondary ischemic outcomes. The increase in ischemic events in the clopidogrel arm suggests that when these patients bleed, it has an adverse impact on their subsequent clinical outcomes. The detriment is not the bleed itself, but the post-bleeding complications that cause patients to fare poorly, according to Dr. Elmariah.

The POPular TAVI trial provides evidence in support of current practices in the United States of refraining from giving clopidogrel to patients who have an indication for OAC.

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