Assessment of Platelet REACtivity After Transcatheter Aortic Valve Replacement The REAC-TAVI Trial

OBJECTIVES The REAC-TAVI (Assessment of platelet REACtivity after Transcatheter Aortic Valve Implantation) trial enrolled patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) pre-treated with aspirin thorn clopidogrel, aimed to compare the efficacy of clopidogrel and ticagrelor in suppressing high platelet reactivity (HPR) after TAVI. BACKGROUND Current recommendations support short-term use of aspirin thorn clopidogrel for patients with severe AS undergoing TAVR despite the lack of compelling evidence. METHODS This was a prospective, randomized, multicenter investigation. Platelet reactivity was measured at 6 different time points with the VerifyNow assay (Accriva Diagnostics, San Diego, California). HPR was defined as (P2Y12 reaction units (PRU) $ 208. Patients with HPR before TAVR were randomized to either aspirin thorn ticagrelor or aspirin thorn clopidogrel for 3 months. Patients without HPR continued with aspirin thorn clopidogrel (registry cohort). The primary endpoint was non-HPR status (PRU < 208) in $ 70% of patients treated with ticagrelor at 90 days post-TAVR. RESULTS A total of 68 patients were included. Of these, 48 (71%) had HPR (PRU 273 +/- 09) and were randomized to aspirin thorn ticagrelor (n = 24, PRU 277 +/- 08) or continued with aspirin thorn clopidogrel (n = 24, PRU 269 +/- 49). The remaining 20 patients (29%) without HPR (PRU 133 +/- 12) were included in the registry. Overall, platelet reactivity across all the study time points after TAVR was lower in patients randomized to ticagrelor compared with those treated with clopidogrel, including those enrolled in the registry (p < 0.001). The primary endpoint was achieved in 100% of patients with ticagrelor compared with 21% with clopidogrel (p < 0.001). Interestingly, 33% of clopidogrel responder patients at baseline developed HPR status during the first month after TAVR. CONCLUSIONS HPR to clopidogrel is present in a considerable number of patients with AS undergoing TAVR. Ticagrelor achieves a better and faster effect, providing sustained suppression of HPR to these patients. (Platelet Reactivity After TAVI: A Multicenter Pilot Study [REAC-TAVI]; NCT02224066) (J Am Coll Cardiol Intv 2019; 12: 22-32) (c) 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.