Single versus dual antiplatelet therapy after transcatheter aortic valve implantation in patients without an indication for anticoagulation: a systematic review and meta-analysis
C Sanchez Serrano, G Payro-Ramirez, A G Bautista-Viveros, S Parga-Martin, T A Godinez-FloresAbstract
Background
The antiplatelet therapy following transcatheter aortic valve implantation (TAVI) remains controversial; lifelong single antiplatelet therapy (SAPT) is recommended in patients without an indication for oral anticoagulation, although dual antiplatelet therapy (DAPT) is routinely prescribed in patients at low bleeding risk. Balancing the prevention of thromboembolic events against the risk of bleeding is the cornerstone in the management of patients after TAVI.
Purpose
To evaluate whether single antiplatelet therapy improves safety and provides comparable ischemic protection to dual antiplatelet therapy following a TAVI in patients without an indication for oral anticoagulation.
Methods
A systematic search of PubMed, Embase, and Cochrane library databases (inception-February 2026) identified randomized trials and comparative observational studies enrolling post-TAVI patients without an indication for chronic anticoagulation. Studies comparing single antiplatelet therapy versus dual antiplatelet therapy were included. The primary outcomes were major or life-threatening bleeding and any bleeding. Secondary outcomes were stroke, myocardial infarction, all-cause mortality, and cardiovascular mortality. Pooled risk ratios were calculated using random-effects models in Review Manager.
Results
Eight studies (3 randomized trials and 5 cohort studies), comprising 15,222 patients, were included. Outcomes were analyzed by follow-up duration, with assessments at early (30 days) and mid-term (≥90 days). During mid-term follow-up, SAPT showed a non-significant trend toward lower major bleeding or life-threatening bleeding (RR 0.79, 95% CI 0.46 - 1.33) and any bleeding (RR 0.80, 95% CI (0.60 - 1.06) compared with DAPT; no ischemic benefit of DAPT was observed for stroke (RR 1.00, 95% CI 0.71 - 1.43) and myocardial infarction (RR 0.96, 95% CI 0.62 - 1.50). Mortality outcomes were similar between antiplatelet strategies (All-cause mortality RR 1.40, 95% CI 0.98 - 1.98; CV mortality RR 1.70, 95% CI 0.80 - 3.65). Early outcomes were consistent with mid-term findings.
Conclusions
Single antiplatelet therapy in post-TAVI patients provides a comparable ischemic protection against dual antiplatelet therapy, with a tendency to lower bleeding events. DAPT does not provide consistent reductions in stroke, myocardial infarction, and mortality at early and mid-term follow-up. Routine use of DAPT after TAVI may not be justified, and treatment strategies should be individualized according to the patient's bleeding-risk profile.Figure 1.Mid-term outcomesFigure 2.Additionally mid-term outcomes