Introduction to Pre-TAVI Medication Management
Transcatheter Aortic Valve Implantation (TAVI), also known as Transcatheter Aortic Valve Replacement (TAVR), has become a primary treatment for patients with severe aortic stenosis, particularly those at intermediate or high risk for traditional open-heart surgery [1.6.2]. A critical component of preparing for a TAVI procedure is the careful management of a patient's current medications. The primary goal is to minimize the risk of complications, especially bleeding, which can be significant during and after the procedure [1.4.1]. An assessment of the patient's bleeding risk is mandatory before the procedure [1.4.3]. Healthcare providers will provide specific instructions tailored to each patient's health profile, comorbidities, and the procedural approach. Patients must provide a complete list of all medications, including over-the-counter drugs and supplements, to their cardiology team [1.2.1].
Anticoagulants (Blood Thinners)
Anticoagulants are a primary concern due to the increased risk of bleeding during TAVI [1.2.1, 1.4.1]. The interruption of these medications is carefully timed to balance the prevention of procedural bleeding against the risk of thromboembolic events.
- Warfarin (Coumadin): Patients are typically instructed to stop taking warfarin 3 to 5 days before the TAVI procedure [1.2.2, 1.2.5]. The goal is to allow the International Normalized Ratio (INR) to fall to an acceptable level. In some cases, bridging therapy with an injectable anticoagulant may be used.
- Direct Oral Anticoagulants (DOACs): This class includes medications like dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis). The standard recommendation is to stop these drugs 3 to 7 days before the procedure, though the exact timing can vary based on the specific drug and the patient's kidney function [1.2.2, 1.2.4, 1.2.5].
Antiplatelet Agents
Antiplatelet therapy management is complex and often depends on the procedural approach (e.g., through the leg versus through the chest) and whether the patient has coronary stents.
- Clopidogrel (Plavix), Ticagrelor (Brilinta), and Prasugrel (Effient): For many TAVI procedures, especially those performed via the leg (transfemoral approach), patients may be told to continue taking these medications without stopping [1.2.4, 1.2.5]. However, some protocols, particularly for chest-based approaches, require stopping these medications 5 days prior to the procedure [1.2.2, 1.2.5]. Recent studies have shown that pre-medication with dual antiplatelet therapy (DAPT) is no longer recommended as it is associated with a higher rate of major vascular complications without a clear benefit in reducing ischemic events [1.4.2].
- Aspirin: Many patients are advised to continue taking low-dose aspirin throughout the pre-TAVI period [1.2.5]. However, for certain procedural types, it may be stopped 2 days beforehand [1.2.5]. For patients without an oral anticoagulant indication, guidelines suggest starting low-dose aspirin pre-TAVI [1.3.1].
Diabetes Medications
Adjusting diabetes medications is essential to prevent both hypoglycemia (low blood sugar) during the fasting period and other metabolic complications.
- Metformin: This medication is usually held on the day of the TAVI procedure and potentially for 48 hours afterward. This is to reduce the risk of lactic acidosis, a rare but serious side effect, especially when contrast dye is used, which can temporarily affect kidney function [1.2.3, 1.5.3, 1.5.9].
- SGLT2 Inhibitors: This class includes drugs like canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance). Due to the risk of euglycemic diabetic ketoacidosis (a condition where the body produces high levels of blood acids called ketones, even with normal blood sugar), it is recommended to stop these medications 3 to 4 days before the procedure [1.5.1, 1.5.3, 1.5.5, 1.5.6].
- Other Oral Hypoglycemics: Agents like sulfonylureas are typically held on the morning of the surgery to prevent hypoglycemia while fasting [1.5.3].
Other Important Medications
- ACE Inhibitors and ARBs: Medications for blood pressure like lisinopril (an ACE inhibitor) or valsartan (an ARB) may be stopped 2 days before the TAVI procedure, as per some institutional protocols, to help manage blood pressure during anesthesia [1.2.2].
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Over-the-counter NSAIDs such as ibuprofen (Advil, Motrin) and naproxen (Aleve) can affect blood clotting and should be stopped about 2 weeks before the procedure [1.2.1, 1.4.9].
Medication Stopping Timeline Comparison
| Medication Class | Examples | Typical Stopping Window Before TAVI | Reason for Stopping |
|---|---|---|---|
| Vitamin K Antagonists | Warfarin (Coumadin) | 3-5 days [1.2.2, 1.2.5] | Reduce bleeding risk |
| DOACs | Apixaban (Eliquis), Rivaroxaban (Xarelto) | 3-7 days [1.2.2, 1.2.4] | Reduce bleeding risk |
| P2Y12 Inhibitors | Clopidogrel (Plavix), Ticagrelor (Brilinta) | Often continued, but may be stopped 5 days prior depending on approach [1.2.2, 1.2.5] | Reduce bleeding risk (if stopped) |
| SGLT2 Inhibitors | Empagliflozin (Jardiance), Dapagliflozin (Farxiga) | 3-4 days [1.5.1, 1.5.6] | Prevent euglycemic ketoacidosis |
| Metformin | Glucophage | Hold on day of procedure [1.2.7, 1.5.3] | Prevent lactic acidosis |
| ACE Inhibitors / ARBs | Lisinopril, Valsartan | May be stopped 2 days prior [1.2.2] | Blood pressure management |
| NSAIDs | Ibuprofen, Naproxen | Up to 2 weeks [1.2.1] | Reduce bleeding risk |
Conclusion
The decision on what medications should be stopped before TAVI is a highly individualized process managed by a multidisciplinary heart team. While general guidelines exist for common drug classes like anticoagulants, antiplatelets, and diabetic agents, the final instructions will always be tailored to the patient. It is absolutely essential for patients to have an open dialogue with their healthcare providers, disclose all medications they are taking, and strictly follow the pre-procedural instructions to ensure the safest and most successful outcome. Post-procedure medication regimens are also critical and will be adjusted based on the new valve and the patient's overall condition [1.2.4].
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health or treatment.
For more detailed guidelines, you may refer to the American College of Cardiology: https://www.acc.org/ [1.4.3]
