Warfarin Benefits Patients After Surgical Aortic Valve Replacement

Postoperative anticoagulation early after surgical aortic valve replacement (SAVR) with a bioprosthetic valve is associated with improved survival and a lower risk for thromboembolic events, although there was an increased risk for major bleeding, new research showed.

METHODOLOGY:
Researchers used claims data from commercially insured and Medicare Advantage enrollees in the United States to identify adult patients who underwent SAVR from 2007 to 2019.
They analyzed groups in which clinical characteristics were balanced by one-to-one propensity score (PS) matching and separately studied patients who underwent isolated SAVR and those who had concomitant coronary artery bypass grafting (CABG).
Of the 10,589 patients who underwent bioprosthetic SAVR, 2930 received early anticoagulation (at least 30 days of continuous prescription coverage) and 7659 did not; after PS matching, 2930 pairs of patients were analyzed.
The primary outcomes were all-cause mortality and thromboembolic events, including ischemic stroke, systemic thromboembolism, pulmonary embolism, and venous thromboembolism.
TAKEAWAY:

At 2 years, warfarin use early postoperatively was associated with a 32% reduced risk for overall mortality (hazard ratio [HR], 0.68; 95% CI, 0.47-1.00; P = .047).
Warfarin prescription early postoperatively was also associated with decreased mortality in patients undergoing isolated SAVR (HR, 0.62; 95% CI, 0.38-0.99; P = .04) or those having concomitant CABG (HR, 0.47; 95% CI, 0.26-0.85; P = .01).
There was a trend toward reduced overall thromboembolism in the warfarin group (sub-distribution HR [SHR], 0.62; 95% CI, 0.35-1.07; P = .09), with similar results for patients undergoing isolated SAVR.
Warfarin prescription was associated with a 1.94-fold increase in risk for major bleeding events (SHR, 1.94; 95% CI, 1.28-2.94; P = .002).
IN PRACTICE:

“There’s often reluctance to prescribe anticoagulant treatment early after surgery due to concerns about bleeding and uncertainty about benefits,” coauthor Hartzell Schaff, MD, a Mayo Clinic cardiovascular surgeon, said in a press release, adding that the small increased hazard of bleeding shown in the study” may be an acceptable risk given the benefits in terms of mortality risk as well as reduced risk of thromboembolism.”

SOURCE:

The work was carried out by researchers with first author Ying Huang, MD, PhD, Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN. It was published online on December 7, 2023, in Mayo Clinic Proceedings.

LIMITATIONS:

Although PS matching was used to minimize patient selection bias, some bias from unmeasured confounders may remain. As researchers didn’t have complete data on aspirin use, because it’s not a prescription drug in the United States, their ability to assess the impact of postoperative aspirin use on outcomes was limited. All study participants had commercial health insurance, so results may not be generalizable to the US population.

DISCLOSURES:

The authors have no relevant conflicts of interest.
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