PERIOPERATIVE MEDICATION OPTIMIZATION AND EARLY CLINICAL OUTCOMES FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT IN SEVERE AORTIC STENOSIS: A PROSPECTIVE OBSERVATIONAL COHORT STUDY

Abstract

Background: Transcatheter aortic valve replacement (TAVR) has become the treatment of choice for patients with high-risk or elderly severe symptomatic aortic stenosis (AS) [1]. However, the complexity of the patients' multi-morbidities and their extensive therapy poses an enormous challenge for peri-interventional pharmacotherapy [16]. This prospective observational cohort study aimed to investigate the prevalence of relevant peri-interventional medication discrepancies and their impact on 30-day outcomes following TAVR in tertiary care cardiovascular hospitals in Rawalpindi, Pakistan [17]. Methods: We prospectively enrolled 120 consecutive adult patients undergoing elective TAVR. Comprehensive standardized multi-disciplinary medication reconciliation was performed at four perioperative milestones: admission, pre-procedure, discharge and 30-day follow up [16]. Patients were divided into two groups based on the presence of any periprocedural medication optimization: those with at least one clinically significant medication discrepancy or non-indication based treatment departure vs those receiving fully optimized pharmacotherapy. The primary endpoint was a 30-day composite clinical endpoint including clinically relevant bleeding (Valve Academic Research Consortium-3 [VARC-3] criteria) [5], acute kidney injury (AKIN/KDIGO criteria) [14], stroke/transient ischemic attack (TIA), symptomatic hypotension requiring vasopressor/inotropic support, unplanned 30-day cardiac readmissions [15] and all-cause mortality. Results: Out of 120 study participants (mean age: 73.4 ± 6.2 years; 43.3% female), 38 patients (31.7%) had at least one clinically significant medication discrepancy while 82 patients (68.3%) underwent fully optimized pharmacotherapy. The primary composite outcome occurred in 28 of the total patients (23.3%). Patients in the medication discrepancy group had a substantially higher incidence of 30-day composite adverse events than patients in the optimized pharmacotherapy group (42.1% vs. 14.6%; Odds Ratio [OR]: 4.23, 95% Confidence Interval [CI]: 1.76 to 10.18, p < 0.001). Specifically, higher rates of acute kidney injury (18.4% vs. 4.9%; p = 0.024), and 30-day unplanned hospital readmissions (21.1% vs. 6.1%; p = 0.019) were observed in the medication discrepancy group. Perioperative medication discrepancy was independently associated with 30-day composite adverse outcomes as demonstrated by multivariable logistic regression analysis (adjusted OR: 3.64, 95% CI: 1.42 to 9.32, p = 0.007). Conclusion: Perioperative medication discrepancies are highly prevalent among TAVR candidates in South Asian clinical practice and significantly increase early morbidity and unplanned hospital readmissions [17]. Systematic clinical pharmacy-led medication reconciliation and strict adherence to indication-based antithrombotic guidelines represent essential strategies to optimize periprocedural safety and enhance post-TAVR recovery [16].