Refer to UpToDate content on indications for anticoagulation.
TAVI: transcatheter aortic valve implantation; DAPT: dual antiplatelet therapy; SAPT: single antiplatelet therapy; VKA: vitamin K antagonist; DOAC: direct oral anticoagulant.
* Therapeutic anticoagulation does not include low-dose heparin therapy for prophylaxis against venous thromboembolic disease. The most common concurrent indication for therapeutic anticoagulation post-TAVI is atrial fibrillation with risk factors favoring anticoagulation (eg, CHA2DS2-VASc score ≥2). The choice and duration of anticoagulant therapy is based upon the indication for anticoagulation. ¶ Common indications for DAPT include recent coronary stent implantation and recent acute coronary syndrome. Δ The choice and duration of antiplatelet and anticoagulant therapy are based upon the indications for these agents. Long-term triple antithrombotic therapy (dual antiplatelet therapy plus anticoagulation) is generally avoided given evidence suggesting worse outcomes compared with dual antithrombotic therapy. ◊ When a patient no longer requires anticoagulation or DAPT, then SAPT is used. § Antiplatelet therapy is not required in this setting. During the first 3 months post-TAVI, VKA is the preferred anticoagulant. After the first 3 months, the choice of anticoagulant (VKA or DOAC) is based upon the indication for anticoagulation and other clinical factors. ¥ DAPT consists of aspirin 75 to 100 mg daily plus clopidogrel 75 mg daily. No loading dose is required for aspirin therapy. Clopidogrel is initiated as a 300 mg loading dose followed by a 75 mg daily maintenance dose. ‡ In this setting, SAPT is generally aspirin 75 to 100 mg daily. If aspirin is contraindicated due to hypersensitivity, clopidogrel is an alternative. † A reasonable alternative is to use DAPT in the intermediate term (during the initial 3 to 6 months depending upon valve type) followed by lifelong SAPT, which is the approach used in the pivotal TAVI trials. If intermediate-term DAPT is chosen, it is continued for the first 6 months (for the SAPIEN valve) or for the first 3 months (for the Evolut R/PRO/PRO-PLUS valve).
