Antiplatelet Therapy After Transcatheter Aortic Valve Replacement (TAVR)

Guideline-Based Standard of Care

The American College of Cardiology recommends clopidogrel 75 mg daily for 3-6 months plus aspirin 75-100 mg daily as the standard antiplatelet regimen after TAVR, with a Class IIb recommendation 1, 2
The American Heart Association suggests that aspirin 75-100 mg daily should be continued lifelong after TAVR 1, 2, 3

The European Society of Cardiology states that the use of ticagrelor as part of triple antithrombotic therapy is not recommended in patients requiring oral anticoagulation after TAVR, due to higher bleeding risk 4, 5
The American College of Cardiology notes that clopidogrel is preferred over ticagrelor due to higher bleeding risk with ticagrelor, with a recommendation to use clopidogrel as the initial antiplatelet of choice in patients receiving anticoagulation during acute coronary syndromes 6

For patients with atrial fibrillation or other indications for anticoagulation after TAVR, anticoagulation should be given as per guidelines for atrial fibrillation in patients with prosthetic valves, and dual antithrombotic therapy (anticoagulant plus clopidogrel) is recommended after a short period of triple therapy 3, 4, 5
For patients with recent coronary stenting, clopidogrel remains the preferred P2Y12 inhibitor when combined with anticoagulation, and ticagrelor might be considered only in patients at exceptionally high risk for stent thrombosis where benefits outweigh bleeding risks 4, 6

The American College of Cardiology advises against extrapolating acute coronary syndrome data to TAVR, as ticagrelor's superiority in acute coronary syndromes does not apply to the TAVR population, which has different thrombotic and bleeding risk profiles 1, 2
The European Society of Cardiology recommends avoiding triple therapy with ticagrelor due to excessive bleeding risk, and considering bleeding risk in TAVR patients who are typically elderly with multiple comorbidities and higher baseline bleeding risk 4, 5, 3