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Valvular heart disease
Original research
Comparison of warfarin versus antiplatelet therapy after surgical bioprosthetic aortic valve replacement
  1. Christina Christersson1,
  2. Stefan K James1,2,
  3. Lars Lindhagen2,
  4. Anders Ahlsson3,4,
  5. Örjan Friberg5,
  6. Anders Jeppsson6,
  7. Elisabeth Ståhle7
  1. 1 Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
  2. 2 Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
  3. 3 Department of Thoracic and Cardiovascular Surgery, Karolinska University Hospital, Stockholm, Sweden
  4. 4 Department of Molecular and Clinical Medicine, Institute of Medicine Sahlgrenska Academy, Gothenburg, Sweden
  5. 5 Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
  6. 6 Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
  7. 7 Department of Surgical Sciences Thoracic Surgery, University Hospital Uppsala, Uppsala, Sweden
  1. Correspondence to Dr Christina Christersson, Cardiology, Medical Sciences, Uppsala, Sweden; christina.christersson{at}medsci.uu.se

Abstract

Objectives To compare effectiveness of warfarin and antiplatelet exposure regarding both thrombotic and bleeding events, following surgical aortic valve replacement with a biological prosthesis(bioSAVR).

Methods The study included all patients in Sweden undergoing a bioSAVR during 2008–2014 who were alive at discharge from the index hospital stay. Exposure was analysed and defined as postdischarge dispension of any antithrombotic pharmaceutical, updated at each following dispensions and categorised as single antiplatelet (SAPT), warfarin, warfarin combined with SAPT, dual antiplatelet (DAPT) or no antithrombotic treatment. Exposure to SAPT was used as comparator. Outcome events were all-cause mortality, ischaemic stroke, haemorrhagic stroke, any thromboembolism and major bleedings. We continuously updated adjustments for comorbidities with any indication for antithrombotic treatment by Cox regression analysis.

Results We identified 9539 patients with bioSAVR (36.8% women) at median age of 73 years with a mean follow-up of 3.13 years. As compared with SAPT, warfarin alone was associated with a lower incidence of ischaemic stroke (HR 0.49, 95% CI 0.35 to 0.70) and any thromboembolism (HR 0.75, 95% CI 0.60 to 0.94) but with no difference in mortality (HR 0.94, 95% CI 0.78 to 1.13). The incidence of haemorrhagic stroke (HR 1.94, 95% CI 1.07 to 3.51) and major bleeding (HR 1.67, 95% CI 1.30 to 2.15) was higher during warfarin exposure. As compared with SAPT, DAPT was not associated with any difference in ischaemic stroke or any thromboembolism. Risk-benefit analyses demonstrated that 2.7 (95% CI 1.0 to 11.9) of the ischaemic stroke cases could potentially be avoided per every haemorrhagic stroke caused by warfarin exposure instead of SAPT during the first year.

Conclusion In patients discharged after bioSAVR, warfarin exposure as compared with SAPT exposure was associated with lower long-term risk of ischaemic stroke and thromboembolic events, and with a higher incidence of bleeding events but with similar mortality.

  • Surgical biological aortic valve prosthesis
  • antithrombotic treatment
  • ischemic stroke
  • thromboembolism
  • haemorrhagic stroke
  • major bleeding
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/heartjnl-2019-315453

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    Footnotes

    • Contributors CC, SKJ and ES contributed substantially to the design of the present study. LL performed the statistical analyses. CC and ES provided the first draft of the manuscript. All coauthors participated in the interpretation of data and critically revised the manuscript. All authors have approved the final version of the manuscript. CC, ES and LL had full access to the database and take responsibility for the integrity and of the data and the data analyses.

    • Funding This work was supported by the European Society of Cardiology, ESC grant for Medical Research Innovation sponsored by Boehringer Ingelheim.

    • Competing interests CC has received lecture fees from Boehringer Ingelheim and Bristol Myers Squibb. SKJ has received institutional research grants from AstraZeneca, Jansen and lecture fees from AstraZeneca, Jansen and Bayer. AJ has received support for investigator-initiated studies, consultant fees and speaker’s honoraria from AstraZeneca and speaker’s honoraria from Boehringer Ingelheim. LL, AA, ÖF and ES have no competing interests to declare.

    • Patient consent for publication Not required.

    • Ethics approval The study was approved by the local ethics committee (log no. 2014/518) and in compliance with the regulations of the Declaration of Helsinki.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement No data are available.