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Wexler NZ, Vogrin S, Brennan AL, Noaman S, Al-Mukhtar O, Haji K, Bloom JE, Dinh DT, Zheng WC, Shaw JA, Duffy SJ, Lefkovits J, Reid CM, Stub D, Kaye DM, Cox N, Chan W. Adverse Impact of Peri-Procedural Stroke in Patients Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2022; 181:18-24. [PMID: 35999069 DOI: 10.1016/j.amjcard.2022.06.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/19/2022] [Accepted: 06/28/2022] [Indexed: 11/01/2022]
Abstract
Peri-procedural stroke (PPS) is an important complication in patients who underwent percutaneous coronary intervention (PCI). The extent to which PPS impacts mortality and outcomes remains to be defined. Consecutive patients who underwent PCI enrolled in the Victorian Cardiac Outcomes Registry (2014 to 2018) were categorized into PPS and no PPS groups. The primary outcome was 30-day major adverse cardiovascular events (MACEs) (composite of mortality, myocardial infarction, stent thrombosis, and unplanned revascularization). Of 50,300 patients, PPS occurred in 0.26% patients (n = 133) (71% ischemic, and 29% hemorrhagic etiology). Patients who developed PPS were older (69 vs 66 years) compared with patients with no PPS, and more likely to have pre-existing heart failure (59% vs 29%), chronic kidney disease (33% vs 20%), and previous cerebrovascular disease (13% vs 3.6%), p <0.01. Among those with PPS, there was a higher frequency of presentation with ST-elevation myocardial infarction (49% vs 18%) and out-of-hospital cardiac arrest (14% vs 2.2%), PCI by way of femoral access (59% vs 46%), and adjunctive thrombus aspiration (12% vs 3.6%), all p = <0.001. PPS was associated with incident 30-day MACE (odds ratio [OR] 2.97, 95% confidence intervals [CIs] 1.86 to 4.74, p <0.001) after multivariable adjustment. Utilizing inverse probability of treatment weighting analysis, PPS remained predictive of 30-day MACE (OR 1.91, 95% CI 1.31 to 2.80, p = 0.001) driven by higher 30-day mortality (OR 2.0, 95% CI 1.35 to 2.96, p = 0.001). In conclusion, in this large, multi-center registry, the incidence of PPS was low; however, its clinical sequelae were significant, with a twofold increased risk of 30-day MACE and all-cause death.
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Affiliation(s)
- Noah Z Wexler
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Sara Vogrin
- Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Samer Noaman
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Omar Al-Mukhtar
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Kawa Haji
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia
| | - Jason E Bloom
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Wayne C Zheng
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - James A Shaw
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - Stephen J Duffy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; The Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Curtain School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Dion Stub
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - William Chan
- Department of Cardiology, Western Health, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, Alfred Health, Melbourne, Victoria, Australia.
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5
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Sawlani NN, Harrington RA, Stone GW, Steg PG, Gibson CM, Hamm CW, Price MJ, Prats J, Deliargyris EN, Mahaffey KW, White HD, Bhatt DL. Impact of Cerebrovascular Events Older Than One Year on Ischemic and Bleeding Outcomes With Cangrelor in Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004380. [PMID: 28039321 DOI: 10.1161/circinterventions.116.004380] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 11/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cangrelor is a potent intravenous adenosine diphosphate-receptor antagonist that in the CHAMPION trials reduced the 48-hour and 30-day rates of ischemic events during percutaneous coronary intervention without an increase in severe bleeding. METHODS AND RESULTS CHAMPION PCI (A Clinical Trial to Demonstrate the Efficacy of Cangrelor), CHAMPION PLATFORM (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition), and CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) were 3 randomized, double-blind, double-dummy trials in which cangrelor was compared with clopidogrel during percutaneous coronary intervention. The effect of cangrelor on ischemic events and bleeding was analyzed in the subgroup of patients with a history of cerebrovascular events at least 1 year prior to randomization; the Breslow-Day test was used to test for interaction of treatment effect in subgroups with and without such a history. The primary efficacy end point was a composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 hours. Among 24 910 randomized patients, 1270 patients (5.1%) had a cerebrovascular event >1 year old, including 650 assigned to cangrelor and 620 assigned to clopidogrel. Consistent with the overall trial results, the rate of the primary efficacy end point was 4.3% in the cangrelor group versus 5.3% in the clopidogrel group (odds ratio 0.80; 95% confidence interval 0.48-1.34; P=0.40; P for interaction =0.97), and the rate of GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) severe bleeding was 0.3% in both groups (P=0.97; P for interaction =0.81). CONCLUSIONS Among patients in the CHAMPION trials with a prior cerebrovascular event at least 1 year before the percutaneous coronary intervention, the efficacy and bleeding profile of cangrelor compared with clopidogrel was similar to that in the overall trial.
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Affiliation(s)
- Neal N Sawlani
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Robert A Harrington
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Gregg W Stone
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Ph Gabriel Steg
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - C Michael Gibson
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Christian W Hamm
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Matthew J Price
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Jayne Prats
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Efthymios N Deliargyris
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Kenneth W Mahaffey
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Harvey D White
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Deepak L Bhatt
- From the Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (N.N.S., D.L.B.); Stanford University Medical School, CA (R.A.H., K.W.M.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY (G.W.S.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., E.N.D.); and Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.).
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