Impact of Bleeding on Mortality After Percutaneous Coronary Intervention

Impact of Postdischarge Bleeding on Long-Term Mortality in Percutaneous Coronary Intervention Patients Taking Oral Anticoagulants

Although postdischarge bleeding (PDB) is known to negatively affect long-term outcome in patients undergoing percutaneous coronary intervention (PCI) with antiplatelet therapy (APT), the prognostic importance of PDB in patients who require both oral anticoagulants (OACs) and APT has not been fully elucidated. Among 3718 consecutive patients who underwent PCI, 302 patients were treated with both OACs and APT. We evaluated the association between PDB and 3-year all-cause mortality, as estimated by a time-updated Cox proportional hazard regression model. We performed nearest-neighbor matching on the propensity score to adjust the differences in baseline characteristics. Among 302 patients treated with OACs and APT, PDB was observed in 98 patients at a median time of 239 days. Patients experienced PDB had significantly higher incidence of 3-year all-cause mortality in the overall cohort and 94 propensity-score-matched pairs (hazard ratio 6.21, 95% confidence interval 3.29-11.72, P < 0.0001; and hazard ratio 6.13, 95% confidence interval 2.68-14.02, P < 0.0001, respectively). The risk of subsequent mortality was the highest within 180 days after PDB (58.3% within 180 days and 75.0% within 1 year). In conclusion, PDB was significantly associated with long-term mortality in patients taking both OACs and APT after PCI.

The effect of CYP2C19 genotype-guided antiplatelet therapy on outcomes of selective percutaneous coronary intervention patients: an observational study

Aim: To observe if personalized antiplatelet therapy according to the CYP2C19 phenotype can improve the outcomes of patients receiving selective percutaneous coronary intervention (PCI). Methods: In this observational study, 677 Chinese patients undergoing selective PCI were divided into gene group (n = 369) and conventional group (n = 308), and given antiplatelet therapy according to the CYP2C19 genotype or clinical features, respectively. Incidence of MACE (death, non-fatal myocardial infarction, and unplanned repeat revascularization) and bleeding was compared between the two groups after 18 months. Results: Diabetes, heart dysfunction and SYNTAX score (>15), but not routinely CYP2C19 genotype test-guided antiplatelet therapy, were associated with MACE. The incidence of bleeding showed no difference. Conclusion: CYP2C19 phenotype-guided antiplatelet therapy may have no influence on the outcomes of selective PCI patients. Clinical features-guided antiplatelet therapy may be reasonable.

Radial versus femoral access in patients with acute coronary syndrome undergoing invasive management: A prespecified subgroup analysis from VALIDATE-SWEDEHEART

AIMS

In the Bivalirudin versus Heparin in ST-Segment and Non-ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated according to Recommended Therapies Registry Trial (VALIDATE-SWEDEHEART), bivalirudin was not superior to unfractionated heparin in patients with acute coronary syndrome undergoing invasive management. We assessed whether the access site had an impact on the primary endpoint of death, myocardial infarction or major bleeding at 180 days and whether it interacted with bivalirudin/unfractionated heparin.

METHODS AND RESULTS

A total of 6006 patients with acute coronary syndrome planned for percutaneous coronary intervention were randomised to either bivalirudin or unfractionated heparin. Arterial access was left to the operator discretion. Overall, 90.5% of patients underwent transradial access and 9.5% transfemoral access. Baseline risk was higher in transfemoral access. The unadjusted hazard ratio for the primary outcome was lower with transradial access (hazard ratio 0.53, 95% confidence interval 0.43-0.67, p<0.001) and remained lower after multivariable adjustment (hazard ratio 0.56, 95% confidence interval 0.52-0.84, p<0.001). Transradial access was associated with lower risk of death (hazard ratio 0.41, 95% confidence interval 0.28-0.60, p<0.001) and major bleeding (hazard ratio 0.57, 95% confidence interval 0.44-0.75, p<0.001). There was no interaction between treatment with bivalirudin and access site for the primary endpoint (p=0.976) or major bleeding (p=0.801).

CONCLUSIONS

Transradial access was associated with lower risk of death, myocardial infarction or major bleeding at 180 days. Bivalirudin was not associated with less bleeding, irrespective of access site.

One-Year Mortality for Bivalirudin vs Heparins Plus Optional Glycoprotein IIb/IIIa Inhibitor Treatment Started in the Ambulance for ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of the EUROMAX Randomized Clinical Trial

Importance

Uncertainty exists regarding potential survival benefits of bivalirudin compared with heparin with routine or optional use of glycoprotein IIb/IIIa inhibitors (GPIs) in patients with ST-segment elevation myocardial infarction (STEMI). Few data are available regarding long-term mortality in the context of contemporary practice with frequent use of radial access and novel platelet adenosine diphosphate P2Y12 receptor inhibitors.

Objective

To assess the effect of bivalirudin monotherapy compared with unfractionated or low-molecular-weight heparin plus optional GPIs on 1-year mortality.

Design, Setting, and Participants

This international, randomized, open-label clinical trial (EUROMAX [European Ambulance Acute Coronary Syndrome Angiography]) included 2198 patients with STEMI undergoing transport for primary percutaneous coronary intervention from March 10, 2010, through June 20, 2013, and followed up for 1 year. Patients were randomized (1:1) in ambulance to bivalirudin monotherapy vs unfractionated or low-molecular-weight heparin plus optional GPIs (control group). Analysis was based on intention to treat.

Main Outcomes and Measures

The primary outcome of this prespecified analysis was 1-year mortality. All deaths were adjudicated as cardiac or noncardiac by an independent, blinded clinical events committee. One-year mortality was assessed and examined across multiple prespecified subgroups.

Results

Of the 2198 patients enrolled (1675 men [76.2%] and 523 women [23.8%]; median [interquartile range] age, 62 [52-72] years), complete 1-year follow-up data were available for 2164 (98.5%). All-cause 1-year mortality occurred in 118 patients (5.4%). The number of all-cause deaths was the same for both treatment groups (59 deaths; relative risk [RR], 1.02; 95% CI, 0.72-1.45; P = .92). No differences were noted in the rates of 1-year cardiac death (44 [4.0%] for the bivalirudin group vs 48 [4.3%] for the control group; RR, 0.93; 95% CI, 0.63-1.39; P = .74) or noncardiac death (15 [1.4%] for the bivalirudin group vs 11 [1.0%] for the control group; RR, 1.39; 95% CI, 0.64-3.01; P = .40). Results were consistent across the prespecified patient subgroups. The rate of deaths occurring from 30 days to 1 year was also similar (27 [2.5%] in the bivalirudin group vs 25 [2.3%] in the control group; RR, 1.10; 95% CI, 0.64-1.88; P = .73).

Conclusions and Relevance

In patients with STEMI who were being transported for primary percutaneous coronary intervention, treatment with bivalirudin or with heparin with optional use of GPI resulted in similar 1-year mortality. The reduced composite end point of death and/or major bleeding at 30 days in the bivalirudin arm of the EUROMAX trial did not translate into reduced cardiovascular or all-cause death at 1 year.

Trial Registration

clinicaltrials.gov Identifier: NCT01087723.

Optimal duration of dual antiplatelet therapy post percutaneous coronary intervention in acute coronary syndrome

Dual antiplatelet therapy (DAPT), with aspirin plus a P2Y12 inhibitor agent, is the cornerstone treatment after percutaneous coronary intervention for acute coronary syndrome. Based on randomized clinical trial using aspirin and clopidogrel, a DAPT duration of 12 months has been recommended after an acute coronary syndrome. Despite the development of more potent antiplatelet agents (i.e. prasugrel and ticagrelor) and the reduction in ischemic recurrences after acute coronary syndrome, 12 months DAPT currently remains the gold standard. However, a significant proportion of patients experience recurrent ischemic events beyond the first 12 months after an acute coronary syndrome. Meanwhile, with more effective antiplatelet agent, bleeding has become a major safety concern on DAPT. Therefore, the ischemic and bleeding risk balance is central considering the duration of DAPT after an acute coronary syndrome. This review aims to report the evidence for an optimization and individualization of DAPT duration after an acute coronary syndrome.

Differences of bleedings after percutaneous coronary intervention using femoral closure and radial compression devices

Bleedings represent most relevant complications being correlated with significant rates of adverse clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). To reduce bleeding and improve prognosis various types of vascular closure devices (VCD) are frequently applied. This study aims to compare directly one specific femoral closure (FC) to one specific radial compression (RC) device in patients after PCI focusing on overall and access-site bleedings as well as major adverse cardiac events (MACE).This single-center, prospective, and observational study included consecutive patients either treated by the FC (StarClose SE) or RC (TR Band) device following PCI. The primary outcome was bleeding; the secondary outcomes were MACE at 30 days of follow-up.Two hundred patients in each group were enrolled following PCI. Access-site bleeding was significantly higher in the FC (43%) compared to the RC (30%) group (P = .001). Most common type of access-site bleeding consisted of hematomas. Of these, small and large hematomas were significantly higher in the FC group (P < .05). No significant differences of MACE were observed in both groups. In multivariable logistic regression models no consistent significant association of any risk factor with bleeding complications was identified.Despite the use of VCD, transfemoral arterial access is still associated with a higher rates of access site bleeding consisting mostly of hematomas compared to trans-radial access, whereas no differences of MACE were observed between FC and RC patients at 30 days follow-up.

Impact of Sex on Comparative Outcomes of Radial Versus Femoral Access in Patients With Acute Coronary Syndromes Undergoing Invasive Management: Data From the Randomized MATRIX-Access Trial

OBJECTIVES

This study sought to assess whether transradial access (TRA) compared with transfemoral access (TFA) is associated with consistent outcomes in male and female patients with acute coronary syndrome undergoing invasive management.

BACKGROUND

There are limited and contrasting data about sex disparities for the safety and efficacy of TRA versus TFA for coronary intervention.

METHODS

In the MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX) program, 8,404 patients were randomized to TRA or TFA. The 30-day coprimary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), defined as death, myocardial infarction, or stroke, and net adverse clinical events (NACE), defined as MACCE or major bleeding.

RESULTS

Among 8,404 patients, 2,232 (26.6%) were women and 6,172 (73.4%) were men. MACCE and NACE were not significantly different between men and women after adjustment, but women had higher risk of access site bleeding (male vs. female rate ratio [RR]: 0.64; p = 0.0016), severe bleeding (RR: 0.17; p = 0.0012), and transfusion (RR: 0.56; p = 0.0089). When comparing radial versus femoral, there was no significant interaction for MACCE and NACE stratified by sex (p_int = 0.15 and 0.18, respectively), although for both coprimary endpoints the benefit with TRA was relatively greater in women (RR: 0.73; p = 0.019; and RR: 0.73; p = 0.012, respectively). Similarly, there was no significant interaction between male and female patients for the individual endpoints of all-cause death (p_int = 0.79), myocardial infarction (p_int = 0.25), stroke (p_int = 0.18), and Bleeding Academic Research Consortium type 3 or 5 (p_int = 0.45).

CONCLUSIONS

Women showed a higher risk of severe bleeding and access site complications, and radial access was an effective method to reduce these complications as well as composite ischemic and ischemic or bleeding endpoints.

Bleeding risk assessment in elderly patients with acute coronary syndrome

Nowadays, elderly people represent a growing population segment with a well known increased risk of both ischemic and bleeding events. Current acute coronary syndrome guidelines, strongly recommend dual antiplatelet therapy (DAPT) with few specific references for aged patients due to lack of evidence. Patients aged ≥ 75 years are misrepresented in the classic derivation trials cohorts. Strategies to reduce the bleeding risk in this group of patients are urgently needed for the daily clinical practice. Identify the specific age related bleeding risk factors and the importance of an integral geriatric assessment remains challenging. Some of the available in-hospital and out-hospital bleeding risk scores have shown a lower to moderate predictive ability in older patients and no specific tools are developed in elderly population. The importance of an appropriate vascular access choice, type and duration of antiplatelet drugs is crucial to reduce the bleeding risk. Increase radial approaches and short DAPT duration leads to reduce hemorrhages. One interesting subgroup of patients is those who need chronic anticoagulation therapy after percutaneous coronary intervention, due to their very high risk of bleeding. New alternatives as dual therapy with oral anticoagulation and only one antiplatlet drug should be considered. In current review, we evaluate the available evidence about bleeding risk in elderly.

Impact of baseline thrombocytopenia on the long-term outcome of patients undergoing elective percutaneous coronary intervention: An analysis of 9,897 consecutive patients

OBJECTIVES

This study aimed to investigate the association between baseline thrombocytopenia and long-term clinical outcomes among patients undergoing elective percutaneous coronary intervention (PCI).

BACKGROUND

Thrombocytopenia (TP) commonly occurs among patients undergoing PCI. However, whether TP has any influence on the outcome of PCI patients remains controversial.

METHODS

We examined 9,897 consecutive patients who underwent elective PCI in Fuwai Hospital from January 2013 to December 2013. Baseline thrombocytopenia was defined as platelet count <150 × 10⁹ /L. We compared data on demographic, clinical, laboratory, and 30-month outcomes between nonthrombocytopenic and thrombocytopenic patients. The primary outcome was death and major adverse cardiovascular events (MACE) during the 30-month follow-up. Logistic regression analyses were performed to identify risk factors of baseline thrombocytopenia.

RESULTS

Baseline thrombocytopenia developed in 1263 (12.76%) patients; of these, 1,172 (11.84%) patients had mild thrombocytopenia and 91 (0.92%) had the moderate or severe type. No differences in all-cause mortality, stent thrombosis, target vessel revascularization, MACE, or bleeding complications were detected between patients with and without thrombocytopenia. Further, advanced age, male sex, previous PCI history, previous myocardial infarction history, and diabetes mellitus history were found to be risk factors of baseline thrombocytopenia.

CONCLUSIONS

Although baseline thrombocytopenia was common among patients who underwent elective PCI, it did not appear to have a clinically significant effect on long-term adverse outcomes, particular bleeding risk. Our results indicated that it seems to be feasible for patients with mild to moderate thrombocytopenia to receive elective PCI as well as guideline-recommended duration of anti-platelet therapy.

Impact of anemia on percutaneous coronary intervention in Chinese patients: A large single center data

OBJECTIVES

To investigate the impact of anemia on 2-year outcomes in patients undergoing contemporary percutaneous coronary intervention (PCI).

BACKGROUND

Whether anemia is an independent predictor of adverse outcomes after PCI is under debate.

METHODS

A total of 10 717 consecutive patients who underwent PCI with available hemoglobin values at Fuwai Hospital were collected. Clinical outcomes were compared between patients with and without anemia both before and after PCI procedure.

RESULTS

Totally, 1348 (12.5%) and 3111 (29.0%) patients presented with pre- and post-PCI anemia according to World Health Organization criteria (hemoglobin level <120 g/L for women or <130 g/L for men), respectively. Anemic patients presented with more baseline clinical risks and more extensive coronary disease than those without anemia. During 2-year follow-up, patients with pre-PCI anemia had higher incidence of bleeding and stroke than those without pre-PCI anemia. Patients with post-PCI anemia experienced higher incidence of all-cause death, myocardial infarction (MI), target vessel revascularization (TVR), bleeding, and major adverse cardiovascular events (MACE) than those without post-PCI anemia. Survival analyses were performed using multivariable Cox proportional hazards models both before and after propensity score matching. Pre-PCI anemia was not an independent risk factor of any adverse clinical events. Post-PCI anemia was not an independent risk factor of all-cause death, but was an independent risk factor of MI, TVR, and MACE.

CONCLUSIONS

Pre-PCI anemia was not an independent risk factor of any adverse clinical events, while post-PCI anemia had a predictable value of MI, TVR, and MACE after PCI.

Bleeding Events After ST-segment Elevation Myocardial Infarction in Patients Randomized to an All-comer Clinical Trial Compared With Unselected Patients

Most studies reporting bleedings in patients with ST-segment elevation myocardial infarction (STEMI) are reports from clinical trials, which may be unrepresentative of incidences in real-life. In this study, we investigated 1-year bleeding and mortality incidences in an unselected STEMI population, and compared participants with nonparticipants of a randomized all-comer clinical trial (The Third DANish Study of Optimal Acute Treatment of Patients with STEMI (DANAMI-3)). Hospital charts were read and bleedings classified according to thrombolysis in myocardial infarction (TIMI) and Bleeding Academic Research Consortium (BARC) criteria in 2,490 consecutive STEMI patients who underwent primary percutaneous coronary intervention in a single, large, and tertiary heart center. Thrombolysis in myocardial infarction minor and/or major bleeding (TMMB) occurred in 4.4% day 0 to 30 and 2.1% day 31 to 365. DANAMI-3 nonparticipants (n = 887) had significantly higher 30-day bleeding rates than DANAMI-3-participants (n = 1,603) (7.2% vs 2.9%, p <0.0001), but not thereafter (p = 0.8). DANAMI-3 nonparticipation was significantly associated with 30-day TMMB (hazard ratio, 1.8, 95% confidence interval, 1.2 to 2.8, p = 0.007), but this did not persist after adjusting for resuscitated cardiac arrest, Killip-class>2 and anemia. Patients with cardiac arrest, Killip-class>2, and anemia accounted for 70.0% of 30-day TMMBs, and the majority of these patients were DANAMI-3 nonparticipants. TMMB day 0 to 30 was associated with increased 30-day mortality (hazard ratio 3.1, 95% confidence interval 1.9 to 5.2, p <0.0001) but not thereafter (p = 0.9). In conclusion, we found that clinical trial (DANAMI-3) nonparticipants had significantly more TMMBs within 30 days than participants. Patients with resuscitated cardiac arrest, anemia, and Killip-class>2 were accountable for a high rate of TMMBs. Bleeding incidences from clinical trials cannot be translated to an unselected STEMI population.

Outcomes of Percutaneous Coronary Interventions in Patients With Anemia Presenting With Acute Coronary Syndrome

OBJECTIVE

To study the influence of anemia on long-term outcomes of patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI).

PATIENTS AND METHODS

The study included 5668 consecutive unique patients with acute coronary syndrome who underwent PCI at Mayo Clinic from January 1, 2004, through December 31, 2014. The patients were stratified on the basis of the presence (hemoglobin [Hgb] level, <13 g/dL in men and <12 g/dL in women) and severity (moderate to severe Hgb level, <11 g/dL in men and women) of pre-PCI anemia and compared with patients without anemia. The primary outcomes were in-hospital and long-term all-cause mortality after balancing baseline comorbidities using the inverse propensity weighting method.

RESULTS

Unadjusted all-cause in-hospital mortality (4.6% [84 of 1831] vs 2.0% [75 of 3837]) and 5-year follow-up mortality (44.4% [509] vs 15.4% [323]) were higher in patients with anemia than in those without anemia (P<.001 for both). After applying inverse propensity weighting analysis, the all-cause in-hospital mortality (2.0% [37] vs 2.0% [75]; P=.85) and 5-year mortality (17.8% [203] vs 15.4% [323]; P=.05) were not significantly different between patients with and without anemia; however, there were higher rates of all-cause 5-year mortality in patients with moderate to severe anemia (22.3% [113] vs 15.4% [323]; P<.001) compared with patients without anemia. The trend in 5-year mortality was driven by increased noncardiac mortality in patients with anemia (10.2% [91] vs 7.1% [148]; P=.04) and moderate to severe anemia (10.4% [52] vs 7.1% [148]; P=.006) when compared with nonanemic patients.

CONCLUSION

After accounting for differences in risk profiles of anemic and nonanemic patients, anemia appeared to be an independent risk factor for increased long-term all-cause and noncardiac mortality.

Impact of Chronic Renal Failure on Ischemic and Bleeding Events at 1 Year in Patients With Acute Coronary Syndrome (from the Multicenter START ANTIPLATELET Registry)

Chronic renal failure (CRF) impairs prognosis in patients with acute coronary syndromes (ACS); the differential impact of CRF on ischemic and bleeding events in the setting of ACS is unclear. We explored the predictive role of CRF, identified by different equations for the glomerular filtration rate estimation, on the occurrence of the composite end point, including both ischemic cardiovascular and major bleeding (major adverse cardiovascular and bleeding events [MACBE]) at 1 year, and its components. We accessed each patients data from 718 participants in the prospective, multicenter, and START ANTIPLATELET registry, performed on patients with ACS. The ability to predict the risk of MACBE was modest and similar for Cockcroft-Gault, MDRD, and CKD-EPI equations (area under the curves: 0.55, 95% confidence interval [CI] 0.47 to 0.63; 0.53, 95% CI 0.45 to 0.61; 0.54, 95% CI 0.46 to 0.62; respectively, overall p = 0.63). The incidence of MACBE in patients with CRF was 12.6 versus 7.4 per 100 patients/year in those with preserved renal function (adjusted odds ratio [OR] 1.80, 1.02 to 3.20, p = 0.045); the absolute excess in events rate due to CRF was higher for ischemic events (3.5%) than for major bleeding (2.6%). The increased occurrence of MACBE was even greater in patients with CRF and concomitant anemia (OR 2.16) and in patients with severe CRF (OR 2.78). In conclusion, our study indicates that, in patients with ACS, CRF impairs the clinical outcome at 1 year, especially when severe and when is concomitant with anemia. CRF is associated with greater absolute increase of ischemic events than major bleeding.

Changes in Periprocedural Bleeding Complications Following Percutaneous Coronary Intervention in The United Kingdom Between 2006 and 2013 (from the British Cardiovascular Interventional Society)

Major bleeding is a common complication after percutaneous coronary intervention (PCI), although little is known about how bleeding rates have changed over time and what has driven this. We analyzed all patients who underwent PCI in England and Wales from 2006 to 2013. Multivariate analyses using logistic regression models were performed to identify predictors of bleeding to identify potential factors influencing bleeding trends over time. 545,604 participants who had PCI in England and Wales between 2006 and 2013 were included in the analyses. Overall bleeding rates decreased from 7.0 (CI 6.2 to 7.8) per 1,000 procedures in 2006 to 5.5 (CI 4.7 to 6.2) per 1,000 in 2013. Increasing age, female sex, GPIIb/IIIa inhibitors use, and circulatory support were independently associated with increased risk of bleeding complications whereas radial access and vascular closure device use were independently associated with decreases in risk. Decreases in bleeding rates over time were associated with radial access site, and changes in pharmacology, but this was offset by greater proportion of ACS cases and the adverse patient clinical demographics. In conclusion, major bleeding complications after PCI have decreased due to changes in access site practice and decreased usage of GPIIb/IIIa inhibitors, but this is offset by the increase of patients with higher propensity to bleed. Changes in access site practice nationally have the potential to significantly reduce major bleeding after PCI.

A Multicenter, Randomized, Double-Blind, and Placebo-Controlled Study of the Effects of Tongxinluo Capsules in Acute Coronary Syndrome Patients with High On-Treatment Platelet Reactivity

Background

High platelet reactivity (HPR) during clopidogrel treatment predicts postpercutaneous coronary intervention (PCI) ischemic events strongly and independently. Tongxinluo capsules (TCs) are a traditional Chinese medicine formulation used as antiplatelet treatment. However, its efficacy against HPR is not known. The aim of the present study was to evaluate the effects of TCs in acute coronary syndrome (ACS) patients with HPR.

Methods

This multicenter, randomized, double-blind, placebo-controlled study prospectively analyzed 136 ACS patients with HPR who underwent PCI. The patients were enrolled from November 2013 to May 2014 and randomized to receive placebo or TCs in addition to standard dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. The primary end points were the prevalence of HPR at 30 days and the mean change in P2Y₁₂reaction units (PRUs) between baseline and 30 days. Survival curves were constructed with Kaplan-Meier estimates and compared by log-rank tests between the two groups.

Results

Both groups had a significantly reduced prevalence of HPR at 30 days versus baseline, but the TC group, compared with the placebo group, had greater reduction (15.8% vs. 24.8%, P = 0.013), especially among patients with one cytochrome P450 2C19 loss of function (LOF) allele (χ² = 2.931, P = 0.047). The TC group also had a lower prevalence of HPR (33.3% vs. 54.2%, t = 5.284, P = 0.022) and superior performance in light transmittance aggregometry and higher levels of high-sensitivity C-reactive protein (hsCRP), but the composite prevalence of ischemic events did not differ significantly (χ² = 1.587, P = 0.208).

Conclusions

In addition to standard DAPT with aspirin and clopidogrel, TCs further reduce PRU and hsCRP levels, especially in patients carrying only one LOF allele. The data suggest that TCs could be used in combination therapy for ACS patients with HPR undergoing PCI.

Sex Differences in Long-Term Clinical Outcomes in Patients With Atrial Fibrillation Undergoing Coronary Stent Implantation

BACKGROUND

Patients with concomitant atrial fibrillation (AF) and coronary stenting are at high risk for both cardiovascular and bleeding events. We aimed to evaluate the influence of sex on long-term clinical outcomes in this patient subset.Methods and Results:We identified 1,450 patients with AF and coronary stenting in a patient-level pooled database from 3 Japanese studies, and compared 3-year clinical outcomes between men and women (n=1,075, and n=375, respectively). The cumulative 3-year incidence of all-cause death was significantly higher in women than in men (26.5% vs. 17.2%, log-rank P<0.001), although after adjusting for confounders, the excess mortality risk of women relative to men was no longer significant (hazard ratio (HR): 1.12, 95% confidence interval (CI): 0.85-1.46, P=0.42). There were no significant differences in the adjusted 3-year risks for myocardial infarction or stroke between men and women (HR: 1.25, 95% CI: 0.62-2.40, P=0.52, and HR: 1.15, 95% CI: 0.75-1.74, P=0.52, respectively). However, both the cumulative 3-year incidence of and adjusted risk for major bleeding were significantly higher in women than in men (17.0% vs. 11.3%, log-rank P=0.002, and HR: 1.47, 95% CI: 1.03-2.07, P=0.03).

CONCLUSIONS

Among patients with concomitant AF and coronary stenting, there were no significant differences in the adjusted 3-year risks for all-cause death, myocardial infarction, and stroke between men and women. However, women as compared with men were associated with excess adjusted risk for major bleeding.

Impact of Baseline Thrombocytopenia on Bleeding and Mortality After Percutaneous Coronary Intervention

It is still controversial whether baseline thrombocytopenia is independently associated with adverse events after percutaneous coronary intervention. We evaluated the influence of baseline thrombocytopenia against ischemic, bleeding and mortality among the 19,353 patients whose baseline platelet counts were available in the pooled database from the 3 studies in Japan. Baseline thrombocytopenia was classified as follows: mild, ≥100 and <150 × 10⁹/L; moderate, ≥50 and <100 × 10⁹/L; and severe, <50 × 10⁹/L. Primary ischemic outcome measure was defined as composite of myocardial infarction and ischemic stroke, and primary bleeding outcome measure was defined by the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded arteries trial as moderate or severe bleeding. There were 2,590 patients (13.4%) with baseline thrombocytopenia comprising 292 patients (1.5%) with moderate/severe (moderate: 277 and severe: 15) thrombocytopenia and 2,298 patients (11.9%) with mild thrombocytopenia, whereas 16,763 patients (86.6%) had no thrombocytopenia. During 3-year follow-up, the adjusted risks of moderate/severe and mild thrombocytopenia relative to none were neutral for primary ischemic outcome (hazard ratio [HR] 1.07 [95% confidence interval [CI] 0.72 to 1.60], p = 0.74, and HR 0.93 [0.79 to 1.09], p = 0.37, respectively) but were significantly higher for primary bleeding outcome (HR 2.35 [1.80 to 3.08], p <0.001, and HR 1.20 [1.03 to 1.40], p = 0.02), and for mortality (HR 2.34 [1.87 to 2.93], p <0.001, and HR 1.26 [1.11 to 1.43], p <0.001). In conclusion, patients with baseline thrombocytopenia, even a mild one, had a higher risk of bleeding events and all-cause death, but not for ischemic events after percutaneous coronary intervention.

Safety of Reversing Anticoagulation by Protamine Following Elective Transfemoral Percutaneous Coronary Intervention in the Drug-Eluting Stent Era

Bleeding complications following percutaneous coronary interventions (PCI) have been closely associated with morbidity and mortality. Although radial arteries have been widely used in current PCI, including primary PCI, transfemoral PCI remains necessary for complex PCI. The purpose of this study was to compare the incidence of complications following elective transfemoral PCI between manual compression with and without protamine. We identified 249 consecutive patients who underwent elective transfemoral PCI from hospital records, and divided them into two groups: patients who used protamine for manual compression (the protamine group; n = 205) and patients who did not (the non-protamine group, n = 44). Complications including acute thrombosis, bleeding requiring blood transfusion, transient hypotension, skin rash, and death within 30 days were compared between groups. The baseline clinical and procedural characteristics were comparable between the protamine and non-protamine groups. The incidences of all complications were not different between the protamine (5.9%) and the non-protamine groups (9.1%) (P = 0.43). While more than 90% of the patients received drug-eluting stent implantation, there was no acute thrombus in either group. The incidence of bleeding requiring blood transfusion was significantly lower in the protamine group (0.5%) than in the non-protamine group (6.8%) (P = 0.002). Multivariate logistic regression analysis revealed the inverse association between protamine use and bleeding requiring blood transfusion (odds ratio 0.08, 95% confidence interval 0.01-0.84, P = 0.04). In conclusion, the use of protamine for manual compression following elective transfemoral PCI was safe and was associated with less bleeding complications.

Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.

Relation of Bleeding Events to Mortality in Patients With ST-Segment Elevation Myocardial Infarction Treated by Percutaneous Coronary Intervention (a DANAMI-3 Substudy)

Bleeding events in relation to treatment of ST-segment elevation myocardial infarction (STEMI) have previously been associated with mortality. In this study, we investigated the incidence and prognosis of, and variables associated with serious bleedings within 30 days after primary percutaneous coronary intervention in patients from The Third Danish Study of Optimal Acute Treatment of Patients with ST-Segment Elevation Myocardial Infarction (DANAMI-3) (n = 2,217). Hospital charts were read within 30 days postadmission to assess bleeding events using thrombolysis in myocardial infarction (TIMI) and Bleeding Academic Research Consortium criteria. TIMI minor/major bleeding (TMMB) occurred in 59 patients (2.7%). Variables associated with TMMB were female gender (hazard ratio [HR] 3.9, 95% confidence interval [CI] 2.2 to 6.7, p <0.0001), symptom-to-catheterization time >3 hours (HR 1.9, 95% CI 1.1 to 3.3, p = 0.02), use of glycoprotein IIb/IIIa inhibitor (HR 2.1, 95% CI 1.2 to 3.7, p = 0.01), and increasing S-creatinine (HR 1.1, 95% CI 1.0 to 1.2, p = 0.001). Undergoing 2 in-hospital procedures were not associated with increased risk of TMMB. TMMB was strongly associated with 30-day mortality in multivariable analysis (HR 4.8, 95% CI 2.2 to 10.4, p <0.0001) but not with mortality days 31 to 365. When excluding fatal bleedings from the analysis, a TMMB was no longer associated with 30-day mortality. In conclusion, we found that in a contemporary STEMI-population, the incidence of 30-day TMMB was low. A TMMB was strongly associated with 30-day mortality but not with mortality days 31 to 365. If patients survived a serious bleeding, their short- and long-term prognoses were not affected.

Temporal changes in radial access use, associates and outcomes in patients undergoing PCI using rotational atherectomy between 2007 and 2014: results from the British Cardiovascular Intervention Society national database

AIMS

Access site choice for cases requiring rotational atherectomy (PCI-ROTA) is poorly defined. Using the British Cardiovascular Intervention Society PCI database, temporal changes and contemporary associates/outcomes of access site choice for PCI-ROTA were studied.

METHODS AND RESULTS

Data were analysed from 11,444 PCI-ROTA procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes.

RESULTS

For PCI-ROTA, radial access increased from 19.6% in 2007 to 58.6% in 2014. Adoption of radial access was slower in females, those with prior CABG, and in patients with chronic occlusive (CTO) or left main disease. In 2013/14, the strongest predictors of femoral artery use were age (OR 1.02, [1.005-1.036], P = .008), CTO intervention (OR 1.95, [1.209-3.314], P = .006), and history of previous CABG (OR 1.68, [1.124-2.515], P = .010). Radial access was associated with reductions in overall length of stay, and increased rates of same-day discharge. Procedural success rates were similar although femoral access use was associated with increased access site complications (2.4 vs. 0.1%, P < .001). After adjustment for baseline differences, arterial complications (OR 15.6, P < .001), transfusion (OR 12.5, P = .023) and major bleeding OR 6.0, P < .001) remained more common with FA use. Adjusted mortality and MACE rates were similar in both groups.

CONCLUSIONS

In contemporary practice, radial access for PCI-ROTA results in similar procedural success when compared to femoral access but is associated with shorter length of stay, and lower rates of vascular complication, major bleeding and transfusion.

4-Step Protocol for Disparities in STEMI Care and Outcomes in Women

BACKGROUND

Women with ST-segment elevation myocardial infarction (STEMI) receive suboptimal care and have worse outcomes than men. Whether strategies to reduce STEMI care variability impact disparities in the care and outcomes of women with STEMI is unknown.

OBJECTIVES

The study assessed the care and outcomes of men versus women with STEMI before and after implementation of a comprehensive STEMI protocol.

METHODS

On July 15, 2014, the authors implemented: 1) emergency department catheterization lab activation; 2) STEMI Safe Handoff Checklist; 3) immediate transfer to an immediately available catheterization lab; and 4) radial first approach to percutaneous coronary intervention (PCI). The authors prospectively studied consecutive patients with STEMI and assessed guideline-directed medical therapy (GDMT) before PCI, median door-to-balloon time (D2BT), in-hospital adverse events, and 30-day mortality stratified by sex before (January 1, 2011 to July 14, 2014; control group) and after (July 15, 2014 to December 31, 2016) implementation of the STEMI protocol.

RESULTS

Of 1,272 participants (68% men, 32% women), women were older with more comorbidities than men. In the control group, women had less GDMT (77% vs. 69%; p = 0.019) and longer D2BT (median 104 min; [interquartile range (IQR): 79 to 133] min vs. 112 [IQR: 85 to 147] min; p = 0.023). Women had more in-hospital stroke, vascular complications, bleeding, transfusion, and death. In the comprehensive 4-step STEMI protocol, sex disparities in GDMT (84% vs. 80%; p = 0.32), D2BT (89 [IQR: 68 to 106] min vs. 91 [IQR: 68 to 114] min; p = 0.15), and in-hospital adverse events resolved. The absolute sex difference in 30-day mortality decreased from the control group (6.1% higher in women; p = 0.002) to the comprehensive 4-step STEMI protocol (3.2% higher in women; p = 0.090).

CONCLUSIONS

A systems-based approach to STEMI care reduces sex disparities and improves STEMI care and outcomes in women.

Direct Oral Anticoagulants in Addition to Antiplatelet Therapy for Secondary Prevention After Acute Coronary Syndromes: A Systematic Review and Meta-analysis

Importance

Patients with acute coronary syndrome (ACS) remain at high risk for experiencing recurrent ischemic events. Direct oral anticoagulants (DOAC) have been proposed for secondary prevention after ACS.

Objective

To evaluate the safety and efficacy of DOAC in addition to antiplatelet therapy (APT) after ACS, focusing on treatment effects stratified by baseline clinical presentation (non-ST-segment elevation ACS [NSTE-ACS] vs ST-segment elevation myocardial infarction [STEMI]).

Data Sources

PubMed, Embase, BioMedCentral, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched from inception to March 1, 2017.

Study Selection

Randomized clinical trials on DOAC after ACS were evaluated for inclusion. Overall, 473 studies were screened, 19 clinical trials were assessed as potentially eligible, and 6 were included in the meta-analysis.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to abstract data and assess quality and validity. The risk of bias tool, version 2.0 (Cochrane) was used for risk of bias assessment. Data were pooled using random-effects models.

Main Outcomes and Measures

The prespecified primary efficacy end point was the composite of cardiovascular death, myocardial infarction, and stroke. The prespecified primary safety end point was major bleeding.

Results

Six trials that included 29 667 patients were identified (14 580 patients [49.1%] with STEMI and 15 036 [50.7%] with NSTE-ACS). The primary efficacy end point risk was significantly lower in patients who were treated with DOAC as compared with APT alone (odds ratio [OR], 0.85; 95% CI, 0.77-0.93; P < .001). This benefit was pronounced in patients with STEMI (OR, 0.76; 95% CI, 0.66-0.88; P < .001), while no significant treatment effect was observed in patients with NSTE-ACS (OR, 0.92; 95% CI, 0.78-1.09; P = .36; P for interaction = .09). With respect to safety, DOACs were associated with a higher risk of major bleeding as compared with APT alone (OR, 3.17; 95% CI, 2.27-4.42; P < .001), with consistent results in patients with STEMI (OR, 3.45; 95% CI, 1.95-6.09; P < .001) and NSTE-ACS (OR, 2.19; 95% CI, 1.38-3.48; P < .001; P for interaction = .23).

Conclusions and Relevance

To our knowledge, these findings are the first evidence to support differential treatment effects of DOAC in addition to APT according to ACS baseline clinical presentation. In patients with NSTE-ACS, the risk-benefit profile of DOAC appears unfavorable. Conversely, DOAC in addition to APT might represent an attractive option for patients with STEMI.

Transradial Artery Access in Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

Early revascularization is the gold standard for management of patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The use of transradial artery access (TRA) in percutaneous coronary intervention (PCI) has increased in recent years and has emerged as a safe and effective approach to PCI in high-risk patients, with advantages in reduced major bleeding events, other peri-procedural complications, and all-cause mortality when compared with transfemoral artery access (TFA). Multiple randomized clinical trials have demonstrated these advantages of TRA vs. TFA PCI in STEMI patients. Although there remains a lack of dedicated randomized trials in CS, observational data suggest benefits on the same endpoints as in STEMI with TRA vs. TFA PCI in CS. This review summarizes the existing literature on the use of TRA compared to TFA for STEMI and CS patients; the reduction of major bleeding events, other peri-procedural complications, and mortality associated with TRA in STEMI and CS; and technical considerations and challenges in the care of these high-risk patient populations.

Bleeding outcomes after non-emergency percutaneous coronary intervention in the very elderly

Background

Octogenarians constitute an increasing proportion of patients presenting for non-emergency percutaneous coronary intervention (PCI).

Methods

This study evaluated the in-hospital procedural characteristics and outcomes, including the bleeding events of 293 octogenarians presenting between January 2010 and December 2012 for non-emergency PCI to a single large volume tertiary care Australian center. Comparisons were made with 293 consecutive patients aged less than or equal to 60 years, whose lesions were matched with the octogenarians.

Results

Non-ST elevation myocardial infarction was the most frequent indication for non-emergency PCI in octogenarians. Compared to the younger cohort, they had a higher prevalence of co-morbidities and more complex coronary disease, comprising more type C and calcified lesions. Peri-procedural use of low molecular weight heparin (LMWH; 1.0% vs. 5.8%; P < 0.001) and glycoprotein IIb/IIIa inhibitors (2.1% vs. 9.6%; P < 0.001) was lower, while femoral arterial access was used more commonly than in younger patients (80.9% vs. 67.6%; P < 0.001). Overall, there was a non-significant trend towards higher incidence of all bleeding events in the elderly (9.2% vs. 5.8%; P = 0.12). There was no significant difference in access site or non-access site bleeding and major or minor bleeding between the two cohorts. Sub-analysis did not reveal any significant influence on bleeding rates by the use of LMWH, glycoprotein IIb/IIIa inhibitors or femoral arterial access. In addition, there were no significant differences in the rates of in-hospital mortality, stroke or acute stent thrombosis between the two groups.

Conclusions

In this single center study, we did not observe significant increases in adverse in-hospital outcomes including the incidence of bleeding in octogenarians undergoing non-emergency PCI.

Contemporary risk model for inhospital major bleeding for patients with acute myocardial infarction: The acute coronary treatment and intervention outcomes network (ACTION) registry®-Get With The Guidelines (GWTG)®

BACKGROUND

Major bleeding is a frequent complication for patients with acute myocardial infarction (AMI) and is associated with significant morbidity and mortality.

OBJECTIVE

To develop a contemporary model for inhospital major bleeding that can both support clinical decision-making and serve as a foundation for assessing hospital quality.

METHODS

An inhospital major bleeding model was developed using the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) database. Patients hospitalized with AMI between January 1, 2012 and December 31, 2013 across 657 hospitals were used to create a derivation cohort (n=144,800) and a validation cohort (n=96,684). Multivariable hierarchal logistic regression was used to identify significant predictors of major bleeding. A simplified risk score was created to enable prospective risk stratification for clinical care.

RESULTS

The rate of major bleeding in the overall population was 7.53%. There were 8 significant, independent factors associated with major bleeding: presentation after cardiac arrest (OR 2.99 [2.77-3.22]); presentation in cardiogenic shock (OR 2.22 [2.05-2.40]); STEMI (OR 1.72 [1.65-1.80]); presentation in heart failure (OR 1.55 [1.47-1.63]); baseline hemoglobin less than 12 g/dL (1.55 [1.48-1.63]); heart rate (per 10 beat per minute increase) (OR 1.13 [1.12-1.14]); weight (per 10 kilogram decrease) (OR 1.12 [1.11-1.14]); creatinine clearance (per 5-mL decrease) (OR 1.07 [1.07-1.08]). The model discriminated well in the derivation (C-statistic = 0.74) and validation (C-statistic = 0.74) cohorts. In the validation cohort, a risk score for major bleeding corresponded well with observed bleeding: very low risk (2.2%), low risk (5.1%), moderate risk (10.1%), high risk (16.3%), and very high risk (25.2%).

CONCLUSION

The new ACTION Registry-GWTG inhospital major bleeding risk model and risk score offer a robust, parsimonious, and contemporary risk-adjustment method to support clinical decision-making and enable hospital quality assessment. Strategies to mitigate risk should be developed and tested as a means to lower costs and improve outcomes in an era of alternative payment models.

Outcomes in elderly and young patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with bivalirudin versus heparin: Pooled analysis from the EUROMAX and HORIZONS-AMI trials

BACKGROUND

Since older age is a strong predictor of not only bleeding but also of ischemic events, understanding the risk:benefit profile of bivalirudin in the elderly undergoing primary percutaneous coronary intervention (pPCI) for ST-segment elevation (STEMI) is important. For this, we aim to compare elderly with young patients, who all underwent pPCI for STEMI and randomly received either bivalirudin or heparin.

METHODS

We performed a patient-level pooled analysis (n=5800) of two large randomized trials. A total of 2149 (37.1%) elderly patients (>65 years of age) with STEMI were enrolled and randomly assigned to either bivalirudin or heparin with or without a GPI (control group) before pPCI. Clinical outcomes at 30 days were analyzed.

RESULTS

In elderly patients, bivalirudin significantly reduced non-CABG major bleeding (7.1% vs 10.4%; P<.01), subacute ST (0.4% vs 1.5%; P<.01), and net adverse clinical events (NACE; composite of all-cause mortality, reinfarction, IDR, stroke or protocol-defined non-CABG major bleeding [13.7% vs 17.2%; P=.03]) with comparable rates of stroke, MI, acute ST, or all-cause death, when compared with heparin with or without GPI.

CONCLUSIONS

In a large group of elderly patients enrolled in the EUROMAX and HORIZONS-AMI trials, bivalirudin was associated with lower 30-day rates of non-CABG major bleeding, subacute ST and NACE, with similar 30-day rates of acute ST and mortality.

Perioperative management of oral antiplatelet therapy and clinical outcomes in coronary stent patients undergoing surgery

The aim was to investigate the perioperative risk of ischaemic and bleeding events in patients with coronary stents undergoing cardiac and non-cardiac surgery and how these outcomes are affected by the perioperative use of oral antiplatelet therapy. This was a multicentre, retrospective, observational study conducted in patients with coronary stent(s) undergoing cardiac or non-cardiac surgery. The primary efficacy endpoint was the 30-day incidence of major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction (MI) or stroke. The primary safety endpoint was the 30-day incidence of Bleeding Academic Research Consortium (BARC) bleeding ≥ 2. A total of 666 patients were included. Of these, 371 (55.7 %) discontinued their antiplatelet medication(s) (all or partly) before undergoing surgery. At 30 days, patients with perioperative discontinuation of antiplatelet therapy experienced a significantly higher incidence of MACE (7.5 % vs 0.3 %, p < 0.001), cardiac death (2.7 % vs 0.3 %, p=0.027), and MI (4.0 % vs 0 %, p < 0.001). After adjustment, peri-operative antiplatelet discontinuation was the strongest independent predictor of 30-day MACE (odds ratio [OR]=25.8, confidence interval [CI]=3.37–198, p=0.002). Perioperative aspirin (adjusted OR 0.27, 95 % CI 0.11–0.71, p=0.008) was significantly associated with a lower risk of MACE. The overall incidence of BARC ≥ 2 bleeding events at 30-days was significantly higher in patients who discontinued oral antiplatelet therapy (25.6 % vs 13.9 %, p < 0.001). However, after adjustment, antiplatelet discontinuation was not independently associated with BARC ≥ 2 bleeding. In conclusion antiplatelet discontinuation increases the 30-day risk of MACE, in patients with coronary stents undergoing cardiac and non-cardiac surgery, while not offering significant protection from BARC≥ 2 bleeding.

Assessment of bleeding risk in patients with coronary artery disease on dual antiplatelet therapy

Patients with coronary artery disease are usually treated with dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Patients on DAPT are at risk of both ischaemic and bleeding events. Although side-lined for a long time, real-life studies have shown that both the incidence and the associated morbidity and mortality of outof-hospital bleeding are high. This indicates that prevention of (postinterventional) bleeding is as important as prevention of ischaemia. For this purpose it is crucial to reliably identify patients with a high bleeding risk. In order to postulate an algorithm, which could help identifying these patients, we performed a systematic review to determine the value of previously proposed prognostic modalities for bleeding. We searched and appraised the following tools: platelet function tests, genetic tests, bleeding scores and questionnaires and haemostatic tests. Most studies indicated that low on-treatment platelet reactivity (LTPR), as measured by several platelet function tests, and the carriage of CYP2C19*17 allele were independent risk factors for bleeding. A bleeding score also proved to be helpful in identifying patients at risk. No studies on haemostatic tests were retrieved. Several patient characteristics were also identified as independent predictors of bleeding, such as older age, female sex and renal failure. Combining these risk factors we propose an algorithm that would hypothetically facilitate identification of those patients at highest risk, warranting prevention measures for bleeding. This could be a starting point for further research concerning the topic.

Prognostic Impact of in-Hospital-Bleeding in Patients With ST-Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Several studies established a link between bleeding and mortality in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI); however, it is unclear whether bleeding has a direct role in worsening the prognosis or if it is simply a marker of patient frailty. We investigated whether bleeding is an independent predictor of mortality in patients with STEMI treated with pPCI. The relationship between the presence of heart failure on presentation (Killip classification), bleeding occurrence, and outcome was also assessed. Bleeding was defined as the combination of Thrombolysis in Myocardial Infarction major and minor bleeding. Short- and long-term mortalities were estimated using the Kaplan-Meyer analysis. Multivariable analysis was performed by the Cox regression model. As an alternative method to address the potential confounding factors, we performed a propensity-matched analysis adjusted for all variables included in the CRUSADE score. In the 1,911 consecutive patients with STEMI considered, bleeding (observed in 11.4% of patients) was an independent predictor of 30-day (hazard ratio 2.61, 95% confidence interval 1.30 to 5.25, p = 0.007) and 1-year mortality (hazard ratio 1.98, 95% confidence interval 1.13 to 3.47, p = 0.017) but not in a landmark analysis starting from 30 days to 1 year. Bleeding was significantly associated with higher 30-day and 1-year mortality in patients with Killip class ≥II, but not in patients with Killip class I. In conclusion, in-hospital bleeding is independently associated with increased mortality in the early period after STEMI, also after adjusting for variables associated with the risk of bleeding. Bleeding was associated with increased mortality in patients with signs of heart failure at admission, whereas it had no effects in patients with Killip class I.

Bivalirudin versus heparin, without glycoprotein inhibition, in percutaneous coronary intervention: A comparison of ischemic and hemorrhagic outcomes over 10years

OBJECTIVE

The choice of antithrombotic agent used during percutaneous coronary intervention (PCI) is controversial. While earlier studies suggested a reduction in bleeding events with bivalirudin, these studies were confounded by the concomitant use of glycoprotein IIbIIIa inhibitors (GPI) in the heparin group. More recent studies have challenged the superiority of bivalirudin, pointing to an increased risk of stent thrombosis. Real-world data remains limited.

METHODS

We queried our institutional catheterization laboratory database for all PCI cases performed between January 2003 and December 2012 using only heparin or only bivalirudin (no use of GPI). We collected data on relevant patient and procedural characteristics and compared both efficacy and safety outcomes. We adjusted for baseline differences using coarsened exacting matching.

RESULTS

8061 cases met our inclusion criteria. Of these, 34.9% were performed with heparin alone and 65.1% with bivalirudin. After adjusting for baseline differences, we found that those patients receiving heparin had a slightly lower risk of post-procedural abrupt vessel closure (0.1% vs 0.5%). All other outcomes favored bivalirudin including procedural success (97.2% vs 95.5%), transfusion within 72h (2.2% vs 4.8%), retroperitoneal bleeding (0.1% vs 0.8%), and all-cause mortality (0.9% vs 1.9%). Subgroup analysis suggested that outcomes were different only in non-elective cases and non STEMI cases.

CONCLUSION

Heparin appears to offer the advantage of slightly reduced risk of abrupt vessel closure post-procedure but at the cost of increased hemorrhagic complications and all-cause mortality. This difference in outcomes may be limited to non-elective and non STEMI cases with femoral access.

Radial versus femoral access in patients with acute coronary syndromes with or without ST-segment elevation

Aims

To assess whether radial compared with femoral access is associated with consistent outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

Methods and results

In the Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX (MATRIX) programme patients were randomized to radial or femoral access, stratified by STEMI (2001 radial, 2009 femoral) and NSTE-ACS (2196 radial, 2198 femoral). The 30-day co-primary outcomes were major adverse cardiovascular events (MACE), defined as death, myocardial infarction, or stroke, and net adverse clinical events (NACE), defined as MACE or major bleeding In the overall study population, radial access reduced the NACE but not MACE endpoint at the prespecified 0.025 alpha. MACE occurred in 121 (6.1%) STEMI patients with radial access vs. 126 (6.3%) patients with femoral access [rate ratio (RR) = 0.96, 95% CI = 0.75-1.24; P = 0.76] and in 248 (11.3%) NSTE-ACS patients with radial access vs. 303 (13.9%) with femoral access (RR = 0.80, 95% CI = 0.67-0.96; P = 0.016) (Pint = 0.25). NACE occurred in 142 (7.2%) STEMI patients with radial access and in 165 (8.3%) patients with femoral access (RR = 0.86, 95% CI = 0.68-1.08; P = 0.18) and in 268 (12.2%) NSTE-ACS patients with radial access compared with 321 (14.7%) with femoral access (RR = 0.82, 95% CI = 0.69-0.97; P = 0.023) (Pint = 0.76). All-cause mortality and access site-actionable bleeding favoured radial access irrespective of ACS type (Pint = 0.11 and Pint = 0.36, respectively).

Conclusion

Radial as compared with femoral access provided consistent benefit across the whole spectrum of patients with ACS, without evidence that type of presenting syndrome affected the results of the random access allocation.

Characterization of the Average Daily Ischemic and Bleeding Risk After Primary PCI for STEMI

BACKGROUND

The risk of recurrent ischemic and bleeding events after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) may not be uniform over time, which may affect the benefit-to-risk ratio of guideline-recommended antithrombotic therapies in different intervals.

OBJECTIVES

This study sought to characterize the average daily ischemic rates (ADIRs) and average daily bleeding rates (ADBRs) within the first year after primary PCI for STEMI.

METHODS

Among 3,602 patients with STEMI who were enrolled in the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial, all ischemic and bleeding events, including recurrent events, were classified according to the timing of their occurrence as acute (≤24 h after PCI), subacute (1 day to 30 days), and late (30 days to 1 year). Patients were treated with aspirin and clopidogrel for the entire year. ADIRs included cardiac death, reinfarction, and definite stent thrombosis. ADBRs included non-coronary artery bypass graft-related Thrombolysis In Myocardial Infarction major and minor bleeding. ADIRs and ADBRs were calculated as the total number of events divided by the number of patient-days of follow-up in each interval assuming a Poisson distribution. Generalized estimating equations were used to test the absolute least square mean differences (LSMD) between ADIRs and ADBRs.

RESULTS

The ADIR and ADBR both exponentially decreased from the acute to the late periods (p < 0.0001). Although there were no significant differences in ADIR and ADBR in the acute phase (LSMD: +0.11%; 95% confidence interval [CI]: -0.35% to 0.58%; p = 0.63), the ADBR was greater than the ADIR in the subacute phase (LSMD: -0.39%; 95% CI: -0.58% to -0.20%; p < 0.0001). In the late phase, the ADIR exceeded the ADBR (LSMD: +1.51%; 95% CI: 1.04% to 1.98%; p < 0.0001).

CONCLUSIONS

After primary PCI, the ADIR and ADBR both markedly decreased over time. Although the rates for bleeding exceeded those for ischemia within 30 days, the daily risk of ischemia significantly exceeded the daily risk of bleeding beyond 30 days, supporting the use of intensified platelet inhibition during the first year after STEMI.

Dual antiplatelet therapy for secondary prevention of coronary artery disease

Dual antiplatelet therapy (DAPT) combining aspirin and a P2Y₁₂ receptor inhibitor has been consistently shown to reduce recurrent major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) compared with aspirin monotherapy, but at the expense of an increased risk of major bleeding. Nevertheless, the optimal duration of DAPT for secondary prevention of CAD remains uncertain, owing to the conflicting results of several large randomised trials. Among patients with stable CAD undergoing PCI with drug-eluting stents (DES), shorter durations of DAPT (3–6 months) were shown non-inferior to 12 or 24 months duration with respect to MACE, but reduced the rates of major bleeding. Contrariwise, prolonged DAPT durations (18–48 months) reduced the incidence of myocardial infarction and stent thrombosis, but at a cost of an increased risk of major bleeding and all-cause mortality. Until more evidence becomes available, the choice of optimal DAPT regimen and duration for patients with CAD requires a tailored approach based on the patient clinical presentation, baseline risk profile and management strategy. Future studies are however needed to identify patients who may derive benefit from shortened or extended DAPT courses for secondary prevention of CAD based on their individual ischaemic and bleeding risk. Based on limited evidence, 12 months duration of DAPT is currently recommended in patients with ACS irrespective of their management strategy, but large ongoing randomised trials are currently assessing the efficacy and safety of a short-term DAPT strategy (3–6 months) for patients with ACS undergoing PCI with newer generation DES. Finally, several ongoing, large-scale, randomised trials are challenging the current concept of DAPT by investigating P2Y₁₂ receptor inhibitors as single antiplatelet therapy and may potentially shift the paradigm of antiplatelet therapy after PCI in the near future. This article provides a contemporary state-of-the-art review of the current evidence on DAPT for secondary prevention of patients with CAD and its future perspectives.

Patients with non-ST segment elevation acute coronary syndromes managed without coronary revascularization: A population needing treatment improvement

NSTE-ACS patients are a heterogeneous population, with different clinical features and prognosis. A large proportion of them is medically managed, without any revascularization. In the EYSHOT and FAST-MI registries such patients were 40% and 35%, respectively. These patients are at higher risk of adverse cardiovascular events and have a worse prognosis compared with those receiving revascularization. Medically managed NSTE-ACS patients consist of different subgroups: those not undergoing coronary angiography, those without significant coronary artery disease, and those with coronary stenoses not referred to revascularization. Patients with NSTE-ACS for whom a conservative strategy without coronary angiogram is planned must be very carefully selected. In patients with comorbidities, frailty, or advanced age, a careful balance between benefits and risks is needed to choice the management strategy (perform or not coronary angiography and/or revascularization), as evidence-based medicine data are lacking in the setting of frailty and comorbidities. In this decisional process, it should be also taken into consideration the role of coronary anatomy in risk stratification and treatment guidance. NSTE-ACS patients managed without revascularization less frequently receive guideline-recommended pharmacological treatment. Dual antiplatelet therapy (DAPT) is recommended for 12months also in medically managed patients, after careful balancing of ischemic and bleeding risk. In these patients it is mandatory to optimize pharmacological treatment, including antiplatelet therapy, to improve outcome. In NSTE-ACS medically managed, the proportion of patients discharged with DAPT should be increased in comparison with current practice, and the use of ticagrelor in place of clopidogrel should be considered in selected patients.

Safety, efficiency and cost effectiveness of Bivalirudin: A systematic review

AIM

To review the early and more recent studies of Bivalirudin, to assess the safety, effectiveness, and cost benefits of this drug.

METHODS

Literature search of MEDLINE and PubMed databases from 1990 to 2017 using keywords as “bivalirubin” and “angiomax”, combined with the words “safety”, “effectiveness”, “efficiency”, “side effects”, “toxicity”, “adverse effect”, and “adverse drug reaction”.

RESULTS

A total of 66 publications were reviewed. The changes in clinical practice and differences in clinical protocols make it difficult to do direct comparisons of studies among each other. However, most trials showed decreased bleeding complications with bivalirudin, although ischemic complications and mortality were mostly comparable, with some favor towards bivalirudin.

CONCLUSION

Bivalirudin and heparin are both acceptable options according to current ACA/AHA guidelines. Authors conclude however, that that due to bivalirudin safer bleeding profile, it should be the preferred medication for anticoagulation.

Higher Risk of Bleeding in Asians Presenting With ST-Segment Elevation Myocardial Infarction: Analysis of the National Inpatient Sample Database

Bleeding is a major complication in patients presenting with ST-segment elevation myocardial infarction (STEMI). Several studies suggested that Asians are more susceptible to bleeding when treated with antiplatelets, anticoagulants, and thrombolytic agents. In our study, we aimed to investigate the association between Asian ethnicity and bleeding events in patients who presented with STEMI. We analyzed the Nationwide Inpatient Sample database from 2002 to 2013 and identified patients hospitalized with a primary diagnosis of STEMI. We compared clinical outcomes between patients of Asian and white ethnicity. Primary outcome was inhospital major bleeding defined as a composite of intracranial hemorrhage and blood transfusions for bleeding events. After exclusions, an estimated 1 695 680 white and 46 563 Asian patients with STEMI were included in the analysis. Asian patients had a higher incidence of inhospital major bleeding (3.6% vs 2.2%, P < .001) without a significant difference in inhospital mortality (9.3% vs 8.7%, P = .06). Asian ethnicity was an independent predictor for major bleeding (estimated odds ratio: 1.32; 95% confidence interval: 1.16-1.51; P < .001). This increased risk of bleeding would warrant further investigation of optimal treatment strategies tailored for patients with STEMI of Asian ethnicity.

Transition Towards Transradial Approach Improves Outcomes of Acute Myocardial Infarction PCI

INTRODUCTION AND AIM

Transradial (TRA) instead of transfemoral (TFA) approach strategy has been presented in research literature as superior access strategy especially for acute ST elevation myocardial infarction (STEMI) primary percutaneous coronary intervention (PCI). There is a paucity of registry-based data of outcomes from default TRA strategy compared to TFA.

MATERIALS AND METHODS

All-comers STEMI PCI institutional Registry identified 1808 consecutive patients in time-frame of 40 months from 2007 to 2010, without making any exclusions. Moreover, we applied Propensity Score Matching (PSM) to replace randomization, address the potential confounding and selection bias. PSM derived 565 congruent pairs of patients from the groups.

RESULTS

After 30 days the primary composite endpoint of major adverse cardiovascular events (MACE) was in favor of TRA 6.5% vs. 12.4% in TFA group, simultaneously secondary endpoints of death in TRA with rate of 4.8% and with rate of 10.1% in TFA. Moreover, the rate of major access related bleeding was 1.1% in TRA vs. 8.5% in TFA, in contrast the major non-access related bleeding was 1.8% and 2.4% respectively showed no significant difference. One year Kaplan Meier survival plots were in favor of TRA.

CONCLUSIONS

Default transradial access strategy is associated with improved STEMI PCI outcomes.

Associations Between Chronic Kidney Disease and Outcomes With Use of Prasugrel Versus Clopidogrel in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Report From the PROMETHEUS Study

OBJECTIVES

This study sought to compare clinical outcomes in a contemporary acute coronary syndrome (ACS) percutaneous coronary intervention (PCI) cohort stratified by chronic kidney disease (CKD) status.

BACKGROUND

Patients with CKD exhibit high risks for both thrombotic and bleeding events, thus complicating decision making regarding antiplatelet therapy in the setting of ACS.

METHODS

The PROMETHEUS study was a multicenter observational study comparing outcomes with prasugrel versus clopidogrel in ACS PCI patients. Major adverse cardiac events (MACE) at 90 days and at 1 year were defined as a composite of death, myocardial infarction, stroke, or unplanned revascularization. Clinically significant bleeding was defined as bleeding requiring transfusion or hospitalization. Cox regression multivariable analysis was performed for adjusted associations between CKD status and clinical outcomes. Hazard ratios for prasugrel versus clopidogrel treatment were generated using propensity score stratification.

RESULTS

The total cohort included 19,832 patients, 28.3% with and 71.7% without CKD. CKD patients were older with greater comorbidities including diabetes and multivessel disease. Prasugrel was less often prescribed to CKD versus non-CKD patients (11.0% vs. 24.0%, respectively; p < 0.001). At 1 year, CKD was associated with higher adjusted risk of MACE (1.27; 95% confidence interval: 1.18 to 1.37) and bleeding (1.46; 95% confidence interval: 1.24 to 1.73). Although unadjusted rates of 1-year MACE were lower with prasugrel versus clopidogrel in both CKD (18.3% vs. 26.5%; p < 0.001) and non-CKD (10.9% vs. 17.9%; p < 0.001) patients, associations were attenuated after propensity stratification. Similarly, unadjusted differences in 1-year bleeding with prasugrel versus clopidogrel (6.0% vs. 7.4%; p = 0.18 in CKD patients; 2.6% vs. 3.5%; p = 0.008 in non-CKD patients) were not significant after propensity score adjustment.

CONCLUSIONS

Although risks for 1-year MACE were significantly higher in ACS PCI patients with versus without CKD, prasugrel use was 50% lower in patients with renal impairment. Irrespective of CKD status, outcomes associated with prasugrel use were not significant after propensity adjustment. These data highlight the need for randomized studies evaluating the optimal antiplatelet therapy in CKD patients with ACS.