Meta-Analysis of the Prognostic Impact of Anemia in Patients Undergoing Percutaneous Coronary Intervention

Predictive potential of pre-procedural cardiac and inflammatory biomarkers regarding mortality following transcatheter aortic valve implantation: A systematic review and meta-analysis

BACKGROUND

Aortic stenosis (AS) is a common heart valve disease, especially in aging populations. While surgical aortic valve replacement (SAVR) is the standard treatment, many patients are ineligible. Transcatheter aortic valve implantation (TAVI) offers an alternative, especially for high-risk patients, but is not without complications. Identifying biomarkers that predict post-TAVI mortality is essential for optimizing outcomes.

OBJECTIVES

The purpose of this systematic review and meta-analysis is to evaluate the role of cardiac and inflammatory biomarkers in predicting short-term and mid to long-term mortality following TAVI.

METHODS

We searched PubMed, Scopus, Embase, and Web of Science for studies examining the impact of inflammatory and cardiac biomarkers on mortality following TAVI. Mean differences (MDs) and 95 % confidence interval (CI) were calculated using a random-effect model.

RESULTS

Twenty-eight studies involving 10,560 patients were included, with 1867 in the mortality group. Mortality was significantly associated with higher pre-procedural levels of creatinine (0.41; 95 % CI: [0.35, 0.48]), brain natriuretic peptide (0.58; 95 % CI: [0.43, 0.73]), C-reactive protein (0.55; 95 % CI: [0.45, 0.64]), and white blood cell count (0.18; 95 % CI: [0.06, 0.31]), and lower pre-procedural levels of hemoglobin (-0.49; 95 % CI: [-0.60, -0.38]) and albumin (-0.18; 95 % CI: [-0.24, -0.13]). These associations remained statistically significant in subgroup analyses for both mid to long-term mortality and short-term mortality, except for WBC levels, which were not significantly associated with short-term mortality, and Hb, for which short-term data were insufficient. Platelet count showed no significant difference.

CONCLUSION

These findings highlight the importance of inflammatory and cardiac biomarkers in risk stratification and patient management in TAVI procedures.

Long-term outcomes of high bleeding risk patients undergoing percutaneous coronary intervention: a Korean nationwide registry

BACKGROUND AND AIMS

Patients with high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI) are at increased risk of not only bleeding, but also ischaemic events. This study aimed to determine the long-term relative risk of ischaemic and bleeding events in HBR patients.

METHODS

This study was a nationwide cohort study, based on the Korean National Health Insurance Review and Assessment Service database. Patients diagnosed with stable angina or acute coronary syndrome and those who underwent PCI in Korea between 2009 and 2018 were included in the analysis. According to the Academic Research Consortium HBR criteria, the total population was divided into HBR and non-HBR groups. The co-primary outcomes were major bleeding events and ischaemic (composite of cardiac death, myocardial infarction, and ischaemic stroke) events.

RESULTS

Among a total of 325 417 patients who underwent PCI, 66 426 patients (20.4%) had HBR. During the follow-up period, HBR patients had a higher risk for major bleeding events (23.9% vs. 8.9%, P < .001) and ischaemic events (33.8% vs. 14.4%, P < .001). However, the impact of HBR was significant for major bleeding events [hazard ratio (HR) 3.12, 95% confidence interval (CI) 3.04-3.21, P < .001] and for ischaemic events (HR 2.50, 95% CI 2.45-2.56, P < .001). The HBR group was also associated with a greater risk of all-cause mortality (HR 3.73, 95% CI 3.66-3.79, P < .001). The average annual rate of major bleeding events within the first year after PCI was 5.5% for a single major criterion, and 2.9% for a single minor criterion.

CONCLUSIONS

Among patients undergoing PCI, those with HBR were at increased long-term risk for both bleeding and ischaemic events, with a greater risk of mortality compared to non-HBR patients.

Implications of anemia in patients undergoing PCI with Impella-support: insights from the PROTECT III study

Background

Anemia is prevalent among patients with cardiovascular disease and is associated with adverse outcomes. However, data regarding the impact of anemia in high-risk percutaneous coronary intervention (HRPCI) are limited.

Objectives

This study aimed to evaluate the impact of anemia in patients undergoing Impella-supported HRPCI in the PROTECT III study.

Methods

Patients undergoing Impella-supported HRPCI in the multicenter PROTECT III study were assessed for anemia based on baseline hemoglobin levels according to World Health Organization criteria. Patients were stratified into three groups, namely, no anemia, mild anemia, and moderate or severe anemia. Major adverse cardiovascular and cerebrovascular events (MACCE: all-cause death, myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) at 30 and 90 days, and major bleeding events were compared across groups.

Results

Of 1,071 patients with baseline hemoglobin data, 37.9% had no anemia, 43.4% had mild anemia, and 18.7% had moderate or severe anemia. Anemic patients were older and more likely to have comorbidities. Anemia was associated with higher MACCE rates at 30 days (moderate to severe, 12.3%; mild, 9.8%; no anemia, 5.4%; p = 0.02) and at 90 days (moderate to severe, 18.7%; mild, 14.6%; none, 8.3%; p = 0.004). These differences persisted after adjustment for potential confounders at 30 and 90 days, and sensitivity analysis excluding dialysis showed similar results. Major bleeding at 30 days was also higher in anemic patients (5.5% vs. 1.2%, p = 0.002).

Conclusion

Baseline anemia in Impella-supported HRPCI is common and independently associated with MACCE and major bleeding, emphasizing its significance as a prognostic factor. Specific management strategies to reduce anemia-associated MACCE risk after HRPCI should be examined. Clinical Trial Information Trial Name: The Global cVAD Study (cVAD)ClinicalTrial.gov Identifier: NCT04136392URL: https://clinicaltrials.gov/ct2/show/NCT04136392?term=cvad&draw=2&rank=2.

Prognosis of anemic patients with atrial fibrillation undergoing percutaneous coronary intervention

BACKGROUND

There are limited data regarding whether anemia is associated with adverse clinical outcomes in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI).

METHODS

Patients with AF undergoing PCI at 15 institutions between January 2015 and March 2021 were included in this analysis. Based on the baseline hemoglobin levels, moderate to severe anemia was defined as hemoglobin levels <11 g/dL, and mild anemia was defined as hemoglobin levels 11-12.9 g/dL for men and 11-11.9 g/dL for women. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE: all-cause death, myocardial infarction, stent thrombosis, and stroke) and major bleeding events (BARC 3 or 5), were compared among patients with moderate/severe anemia, mild anemia, and no anemia.

RESULTS

In a total of 746 enrolled patients, 119 (16.0%) and 168 (22.5%) patients presented with moderate/severe and mild anemia. The incidence of MACE (22.5%, 11.0%, and 9.1%, log-rank p < 0.001), all-cause death (20.0%, 7.2%, and 4.8%, log-rank p < 0.001), and major bleeding events (10.7%, 6.5%, and 2.7%, log-rank p < 0.001) were the highest in the moderate/severe anemia group compared with the mild and no anemia groups. Multivariable Cox regression analyses determined moderate/severe anemia as an independent predictor for MACE (p = 0.008), all-cause death (p = 0.005), and major bleeding events (p = 0.031) at 1 year after PCI.

CONCLUSION

Moderate/severe anemia was significantly associated with the higher incidence of MACE and all-cause death as well as major bleeding events compared with mild and no anemia in AF patients undergoing PCI.

Readmission Trends and Outcomes of Transcatheter Edge-to-Edge Repair of Mitral Regurgitation With and Without Anemia

BACKGROUND

Anemia is associated with worse clinical outcomes in cardiac patients. We aim to investigate the clinical outcomes and readmission rates in anemic patients undergoing transcatheter edge-to-edge repair (TEER) for severe mitral valve regurgitation (MR).

METHODS

The National Readmissions Database (NRD) from 2015 to 2018 was queried using the ICD-10 codes to identify patients admitted for TEER. Patients were divided into anemic and non-anemic sub-groups. Univariate and multivariate analyses were performed. Cardiovascular outcomes were assessed between cohorts at index admission and readmissions at 30, 90, and 180 days. STATA v.17 was used for analysis (StataCorp LLC, Texas, USA).

RESULTS

Our final cohort included 28,995 patients who had undergone TEER in the United States between 2016 and 2019. About 1,434 (4.9%) had a diagnosis of anemia. The mean age of patients who had TEER with anemia and TEER without anemia was 76.9 ± 10.8 vs. 77.7 ± 10.2, respectively. In the adjusted model, anemic patients had higher odds of acute kidney injury (AKI) (aOR 2.21; 95% [CI 1.81-2.6; p<0.001]), HF (aOR 1.75; 95% [CI 1.28-2.3; p<0.001]), myocardial infarction (MI) (aOR 1.54; 95% [CI 1.01-2.33; p<0.041]), major adverse cardiac and cerebrovascular events (MACCE) (aOR 1.72; 95% [CI 1.2-9-2.3; p<0.001]), and net adverse event (aOR 1.85; 95% [CI 1.32-2.59; p<0.001]). The anemic group's readmission rate was overall higher at 30, 90, and 180 days from 2016 to 2019.

CONCLUSION

Anemia was associated with increased adverse clinical outcomes and more extended hospital stays in patients with anemia who had undergone TEER procedures compared to the non-anemic group.

Performance of the Academic Research Consortium High Bleeding Risk Criteria in Patients With ST-Segment Elevation Myocardial Infarction: A Single Center Study

We assessed the ability of predicting mortality and total in-hospital bleeding and adverse outcomes by the Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). A total of 1441 STEMI patients were recruited: HBR group 354 (25%) patients and non-HBR group of 1087 (75%) patients. A total of 131 patients (9%) had a bleeding complication during hospitalization. The bleeding complications were also categorized according to other conventional bleeding scores. According to these conventional scores, all bleeding categories were associated with HBR. In univariate logistic regression analysis, female gender, diabetes mellitus, hypertension (HT) and HBR were associated with in-hospital bleeding. However, in multivariable analysis only HT (Odds Ratio [OR] 1.528, 95% CI 1.020-2.290; P = .040) and HBR (OR 1.612, 95% CI 1.075-2.428; P = .022) independently predicted total in-hospital bleeding complications. Hospital duration was longer and mortality rate was significantly higher in patients with HBR (OR 8.755, 95% CI 5.864-13.074; P < .01). The ARC-HBR criteria may predict in-hospital bleeding events and adverse outcomes in STEMI patients undergoing pPCI.

The impacts of anemia burden on clinical outcomes in patients with out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) has low survival rates, and few patients achieve a desirable neurological outcome. Anemia is common among OHCA patients and has been linked to worse outcomes, but its impact following the return of spontaneous circulation (ROSC) is unclear. This study examines the relationship between anemia burden and clinical outcomes in OHCA patients.

HYPOTHESIS

Higher anemia burden after ROSC may be related to higher mortality and worse neurologic outcomes.

METHODS

Patients who experienced OHCA and had ROSC were enrolled retrospectively. Anemia burden was defined as the area under curve from the target hemoglobin level over a 72-h period after OHCA. Hemoglobin level was measured at 12-h intervals. The clinical outcomes of the study included mortality and neurological outcomes at Day 30.

RESULTS

The study enrolled 258 nontraumatic OHCA patients who achieved ROSC between January 2017 and December 2021. Among the 162 patients who survived more than 72 h, a higher anemia burden, specifically target hemoglobin levels below 7 (hazard ratio [HR]: 1.129, 95% confidence interval [CI]: 1.013-1.259, p = .029), 8 (HR: 1.099, 95% CI: 1.014-1.191, p = .021), and 9 g/dL (HR: 1.066, 95% CI: 1.001-1.134, p = .046) was associated with higher 30-day mortality. Additionally, anemia burden with target hemoglobin levels below 7 (HR: 1.129, 95% CI: 1.016-1.248; p = .024) and 8 g/dL (HR: 1.088; 95% CI: 1.008-1.174, p = .031) was linked to worse neurological outcomes.

CONCLUSIONS

Anemia burden predicts 30-day mortality and neurological outcomes in OHCA patients who survive more than 72 h. Maintaining higher hemoglobin levels within the first 72 h after ROSC may improve short-term outcomes.

Hospital-Acquired Anemia in Patients with Acute Coronary Syndrome: Epidemiology and Potential Impact on Long-Term Outcome

BACKGROUND

Anemia (either pre-existing or hospital-acquired) is considered an independent predictor of mortality in acute coronary syndromes. However, it is still not clear whether anemia should be considered as a marker of worse health status or a therapeutic target. We sought to investigate the relationship between hospital-acquired anemia and clinical and laboratory findings and to assess the association with mortality and major cardiovascular events at long-term follow-up.

METHODS

Patients consecutively admitted at Niguarda Hospital between February 2014 and November 2020 for an acute coronary syndrome were included in this cohort analysis and classified as anemic at admission (group A), with normal hemoglobin at admission but developing anemia during hospitalization (hospital-acquired anemia) (group B); and with normal hemoglobin levels throughout admission (group C).

RESULTS

Among 1294 patients included, group A included 353 (27%) patients, group B 468 (36%), and group C 473 patients (37%). In terms of cardiovascular burden and incidence of death, major cardiovascular events and bleeding at 4.9-year median follow-up, group B had an intermediate risk profile as compared with A and C. Baseline anemia was an independent predictor of death (hazard ratio 1.51; 95% confidence interval, 1.02-2.25; P = .04) along with frailty, Charlson comorbidity Index, estimated glomerular filtration rate, previous myocardial infarction, and left ventricular ejection fraction. Conversely, hospital-acquired anemia was not associated with increased mortality (hazard ratio 1.18; 95% confidence interval, 0.8-1.75; P = .4).

CONCLUSIONS

Hospital-acquired anemia affects one-third of patients hospitalized for acute coronary syndrome and is associated with age, frailty, and comorbidity burden, but was not found to be an independent predictor of long-term mortality.

Safety of transoesophageal echocardiography during structural heart disease interventions under procedural sedation: a single-centre study

AIMS

The aim of this study was to determine the incidence of transoesophageal echocardiography (TOE)-related adverse events (AEs) during structural heart disease (SHD) interventions and to identify potential risk factors.

METHODS AND RESULTS

We retrospectively analysed 898 consecutive patients undergoing TOE-guided SHD interventions under procedural sedation. TOE-related AEs were classified as bleeding complications, mechanical lesions, conversion to general anaesthesia with intubation, and the occurrence of pneumonia. A follow-up was conducted up to 3 months after the intervention. TOE-related AEs were observed in 5.3% of the patients (n = 48). The highest rate of AEs was observed in the percutaneous mitral valve repair (PMVR) group with 8.2% (n = 32), whereas 4.8% (n = 11) of the patients in the left atrial appendage group and 1.8% (n = 5) in the patent foramen ovale/atrial septal defect group developed a TOE-related AE (P = 0.001). The most frequent AE was pneumonia with an incidence of 2.6% (n = 26) in the total cohort. Bleeding events occurred in 1.8% (n = 16) of the patients, mostly in the PMVR group with 2.1% (n = 8). In the multivariate regression analysis, we found a lower haemoglobin {odds ratio (OR) [95% confidence interval (CI)]: 8.82 (0.68-0.98) P = 0.025} and an obstructive sleep apnoea syndrome (OSAS) [OR (95% CI): 2.51 (1.08-5.84) P = 0.033] to be associated with AE. Furthermore, AEs were related to procedural time [OR (95% CI): 1.01 (1.0-1.01) P = 0.056] and oral anticoagulation [OR (95% CI): 1.97 (0.9-4.3) P = 0.076] with borderline significance in the multivariate regression analysis. No persistent damages were observed.

CONCLUSION

TOE-related AEs during SHD interventions are clinically relevant. It was highest in patients undergoing PMVR. A lower baseline haemoglobin level and an OSAS were found to be associated with the occurrence of a TOE-related AE.

Percutaneous Coronary Angioplasty in Patients with Cancer: Clinical Challenges and Management Strategies

The number of cancer survivors in the United States is projected to increase by 31% by 2030. With advances in early screening, diagnosis and therapeutic strategies, a steadily increasing number of patients are surviving cancer. Coronary artery disease (CAD) is now one of the leading causes of death amongst cancer survivors, with the latter group of patients having a higher risk of CAD compared to the general population. Our review covers a range of specific challenges faced by doctors when considering percutaneous coronary interventions (PCI) in cancer patients; clinical outcomes in cancer patients undergoing PCI, as well as some important technical considerations to be made when making decisions regarding the management strategy in this special population of patients.

The predictive value of hemoglobin to creatinine ratio for contrast-induced nephropathy in percutaneous coronary interventions

OBJECTIVES

Hemoglobin and creatinine levels are important factors for contrast induced nephropathy (CIN) development. Our aim in this study is to investigate the predictive value of hemoglobin to creatinine ratio for CIN development in patients with percutaneous coronary intervention (PCI).

METHODS

A total of 500 patients who underwent PCI in our clinic were evaluated prospectively in terms of CIN. Hemoglobin to creatinine ratio is calculated as baseline hemoglobin/baseline serum creatinine value. glomerular filtration rate (GFR) was calculated with Cockcroft-Gault formula. The definition of CIN includes absolute (≥0.5 mg/dL) or relative increase (≥25%) in serum creatinine at 48-72 h after exposure to a contrast agent compared to baseline serum creatinine values.

RESULTS

CIN was detected in 13.8% (69 patients) of 500 patients. In multivariate lineer regression analysis, hemoglobin to creatinine ratio (beta: -0.227, p=0.03) and ejection fraction (EF) (beta: -0.161, p<0.001), contrast amount used (beta: 0.231, p<0.001) were found to be significant predictors for the development of CIN. In receiver operating characteristics (ROC) analysis; AUC=0.730 (0.66-0.79) for hemoglobin to creatinine ratio, p<0.001, AUC=0.694 (0.62-0.76) for EF, p<0.001 and AUC=0.731 (0.67-0.78) for contrast amount used p<0.001.

CONCLUSIONS

Hemoglobin to creatinine ratio, EF and contrast amount used were independent predictors for CIN development in patients with PCI (NCT04703049).

Red Blood Cell Distribution Width: A Prognostic Marker in Patients With Type B Aortic Dissection Undergoing Endovascular Aortic Repair

Background

Red blood cell distribution width (RDW) is associated with cardiovascular mortality. However, the relationship between preoperative RDW and outcomes after thoracic endovascular aortic repair (TEVAR) in type B aortic dissection (TBAD) remains to be determined.

Methods

We review the records of 678 patients with TBAD and treated with TEVAR in three centers. Patients were divided into two groups according to the admission RDW cut-off by receiver operating characteristic curve analysis [≤13.5% (n = 278) and >13.5% (n = 400)]. The association between RDW and long-term mortality was evaluated using Cox survival analysis. Additionally, we used general additive models (GAM) with restricted cubic splines (RCS) to explore non-linear relationships between RDW and outcomes.

Results

Subjects with a high RDW had significantly higher in-hospital mortality rates (1.4 vs. 4.3%, P = 0.038). A total of 70 subjects died after a median follow-up period of 3.3 years. Kaplan–Meier analysis showed that subjects with an RDW >13.5% had worse survival rates than those with lower RDW values (P < 0.001). Multivariate Cox proportional hazard modeling revealed that an RDW >13.5% was an independent predictor of long-term mortality (adjusted HR = 2.27, P = 0.006). Also, we found that there was a non-linear relationship between RDW and mortality from RCS, and RDW of 13.5% might be an inflection point to distinguish the long-term mortality risk of TBAD patients.

Conclusion

As an inexpensive and routinely measured parameter, RDW holds promise as a novel prognostic marker in patients with TBAD receiving TEVAR. We found that an RDW >13.5% on admission was independently associated with increased long-term mortality.

Long-Term Safety and Efficacy of Prolonged Dual Antiplatelet Therapy according to Baseline Anemia after Percutaneous Coronary Intervention

PURPOSE

We aimed to evaluate the outcomes of prolonged dual antiplatelet therapy (DAPT) depending on baseline anemia after percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

Among the 1470 study participants, 448 (30.5%) were classified as having baseline anemia. We categorized the study population according to baseline anemia and DAPT duration: ≤12-month (m) DAPT (n=226) vs. >12-m DAPT (n=222) in anemic patients, and ≤12-m DAPT (n=521) vs. >12-m DAPT (n=501) in non-anemic patients.

RESULTS

During a follow-up of 80.8 (interquartile range 60.6-97.1) months, anemic patients showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) (26.9% vs. 17.1%, p<0.001) and major bleeding (9.8% vs. 5.1%, p=0.006). Among the non-anemic patients, prolonged DAPT was associated with a reduced rate of MACCEs [inverse probability of treatment weighting (IPTW) adjusted hazard ratio (HR), 0.78; 95% confidence interval (CI), 0.63-0.96; p=0.019] without an increase in major bleeding (IPTW adjusted HR, 1.12; 95% CI, 0.75-1.68; p=0.574). However, prolonged DAPT was not related to the incidence of MACCEs (IPTW adjusted HR, 1.11; 95% CI, 0.88-1.39; p=0.387), with increased major bleeding (IPTW adjusted HR, 2.01; 95% CI, 1.32-3.06; p=0.001) among anemic patients.

CONCLUSION

Although extended DAPT led to a reduction in MACCEs in non-anemic patients, it was related to increased major bleeding without reducing MACCEs in anemic patients.

In-Hospital Characteristics and 30-Day Readmissions for Acute Myocardial Infarction and Major Bleeding in Patients With Active Cancer

There are limited data on readmission with ischemic and major bleeding events in patients with acute myocardial infarction (AMI) with active cancer. The purpose of our study was to evaluate in-hospital characteristics and 30-day readmission rates for recurrent AMI and major bleeding by cancer type in patients with AMI and active cancer. From 2016 through 2018, patients in the Nationwide Readmission Database admitted with AMI and underlying active colon, lung, breast, prostate, and hematological cancers were included. Thirty-day readmission for recurrent AMI and major bleeding were reported. Of 1,524,677 index hospitalizations for AMI, 35,790 patients (2.2%) had cancer (0.9% hematological; 0.5% lung; 0.4% prostate; 0.2% breast; and 0.1% colon). Compared with patients without cancer, patients with cancer were about 6 to 10 years older and had a higher proportion of atrial fibrillation, valvular heart disease, previous stroke, and a greater co-morbidity burden. Of all cancer types, only active breast cancer (adjusted odds ratios 1.82, 95% CI 1.11 to 2.98) was found to be significantly associated with elevated odds of readmission for major bleeding; no such association was observed for recurrent AMI. In conclusion, AMI in patients with breast cancer is associated with significantly greater odds of readmission for major bleeding within 30 days after discharge. Management of patients with concomitant AMI and cancer is challenging but should be based on a multidisciplinary approach and estimation of an individual patient's risk of major coronary thrombotic and bleeding events.

Untangling the difficult interplay between ischemic and hemorrhagic risk: The role of risk scores

BACKGROUND

Bleedings are an independent risk factor for subsequent mortality in patients with acute coronary syndromes (ACS) and in those undergoing percutaneous coronary intervention. This represents a hazard equivalent to or greater than that for recurrent ACS. Dual antiplatelet therapy (DAPT) represents the cornerstone in the secondary prevention of thrombotic events, but the benefit of such therapy is counteracted by the increased hemorrhagic complications. Therefore, an early and individualized patient risk stratification can help to identify high-risk patients who could benefit the most from intensive medical therapies while minimizing unnecessary treatment complications in low-risk patients.

AIM

To review existing literature and gain better understanding of the role of ischemic and hemorrhagic risk scores in patients with ischemic heart disease (IHD).

METHODS

We used a combination of terms potentially used in literature describing the most common ischemic and hemorrhagic risk scores to search in PubMed as well as references of full-length articles.

RESULTS

In this review we briefly describe the most important ischemic and bleeding scores that can be adopted in patients with IHD, focusing on GRACE, CHA2DS2-Vasc, PARIS CTE, DAPT, CRUSADE, ACUITY, HAS-BLED, PARIS MB and PRECISE-DAPT score. In the second part of this review, we try to define a possible approach to the IHD patient, using the most suitable scores to stratify patient risk and decide the most appropriate patient treatment.

CONCLUSION

It becomes evident that risk scores by themselves can’t be the solution to balance the ischemic/bleeding risk of an IHD patient. Instead, some risk factors that are commonly associated with an elevated risk profile and that are already included in risk scores should be the focus of the clinician while he/she is taking care of a patient affected by IHD.

Prognostic Value of Baseline Neutrophil-to-Lymphocyte Ratio Combined With Anemia in Patients With ST-Segment Elevation Myocardial Infarction: A Nationwide Prospective Cohort Study

Objective

Data pertaining to the prognostic value of the combination of high neutrophil-to-lymphocyte ratio (NLR) and anemia on admission in patients with ST-segment elevation myocardial infarction (STEMI) are limited. The objective of this study was to investigate the clinical value of baseline NLR in combination with anemia in predicting clinical outcomes after STEMI.

Methods

A total of 5,194 consecutive patients with STEMI within 12 hours of symptom onset from the Korea Acute Myocardial Infarction Registry-National Institute of Health database between 2011 and 2015 were categorized into 4 groups according to their NLR and hemoglobin levels: low NLR (<4) without anemia (n=2,722; reference group); high NLR (≥4) without anemia (n=1,527); low NLR with anemia (n=508); and high NLR with anemia (n=437). The co-primary outcomes were 180-day and 3-year all-cause mortality.

Results

Mortality rates significantly increased at the 3-year follow-up across the groups (3.3% vs. 5.4% vs. 16.5% vs. 21.7% for 180-day mortality and 5.3% vs. 9.0% vs. 23.8% vs. 33.4% for 3-year mortality; all p-trends <0.001). After adjusting for baseline covariates, the combination of high NLR and anemia was a significant predictor of 180-day mortality after STEMI with low NLR and no anemia as the reference (adjusted hazard ratio, 2.16; 95% confidence interval, 1.58–2.95; p<0.001). Similar findings were observed for the 3-year mortality.

Conclusions

This nationwide prospective cohort study showed that the combination of high NLR (≥4) and anemia is a strong predictor of all-cause mortality after STEMI.

Predictive Value of Red Blood Cell Distribution Width for 1-Year All-Cause Mortality in Critically Ill Patients with Acute Myocardial Infarction

Objective

Red blood cell distribution width (RDW) on admission is a prognostic factor in cardiovascular disease. This study investigated the prognostic value of the RDW measured within 24 hours before discharge (24h dRDW) on 1-year all-cause mortality in critically ill patients with acute myocardial infarction (AMI), and compared the effect of 24h dRDW in anemia and non-anemia patients.

Materials and Methods

Altogether, 4088 patients with AMI were studied retrospectively. Data from the MIMIC-III database were collected and analyzed. The Kaplan–Meier method, Cox regression models, and receiver operating characteristic (ROC) analysis were used to assess the impact of 24h dRDW on all-cause mortality in AMI patients, and a stratified analysis was performed to investigate the prognostic value of 24h dRDW in anemia and non-anemia patients.

Results

Of the 4088 patients, there were 704 non-survivors (17.2%). The non-survivors had a higher RDW than the survivors (p<0.001). Cox regression analysis showed that 24h dRDW had a significant independent association with 1‐year all-cause mortality in critically ill patients with AMI (quintile 5 vs quintile 1, HR, 95% CI: 2.847, 2.014–4.023). The area under the ROC curve of 24h dRDW was 0.710 (95% CI, 0.689–0.730). In the stratified analysis, a significant prognostic value of 24h dRDW was found in anemia patients for 1-year all-cause mortality, but not in non-anemia patients.

Conclusion

Elevated 24h dRDW values are significantly associated with increased hazards of all‐cause mortality in critically ill patients with AMI. Significant prognostic value of 24h dRDW was found in AMI patients with anemia, but not in those without anemia.

Impact of anemia on in-stent restenosis after percutaneous coronary intervention

Background

Anemia is a common risk factor for post-percutaneous coronary intervention (PCI) adverse events; however, data on its association with in-stent restenosis (ISR) is limited.

Methods

538 patients who underwent PCI between January 2017 and September 2019 and follow-up angiography 9–12 months after the initial PCI were enrolled in this study. Baseline clinical and procedural characteristics were compared between the ISR and non-ISR groups, and independent predictors of ISR were determined using propensity score matching.

Results

The incidence of anemia was 53.5% in patients with ISR and 19.0% in those without ISR. Univariable logistic regression analyses showed that anemia (OR, 4.283; 95% CI, 1.949–9.410; P < 0.001), diabetes mellitus (OR, 2.588; 95% CI, 1.176–5.696; P = 0.018), chronic kidney disease (OR, 3.058; 95% CI, 1.289–7.252; P = 0.011), multiple stenting (OR, 2.592; 95% CI, 1.205–5.573; P = 0.015), bifurcation lesion (OR, 2.669; 95% CI, 1.236–5.763; P = 0.012), and calcification (OR, 3.529; 95% CI, 1.131–11.014; P = 0.030) were closely associated with ISR. Low-density lipoprotein cholesterol (LDL-c) levels and stent diameter were also significantly linked to ISR, as was anemia (P = 0.009) after propensity score matching.

Conclusion

Anemia is closely associated with post-PCI ISR, and patients with lower hemoglobin levels are at a higher risk of ISR.

Comparison of Outcomes of Patients With Versus Without Chronic Liver Disease Undergoing Percutaneous Coronary Intervention

There are limited data on the outcomes of chronic liver disease (CLD) patients admitted for percutaneous coronary intervention (PCI). All PCI hospitalizations from the Nationwide Inpatient Sample (2004 to 2015) were analyzed and stratified by the presence, cause and severity of CLD, as well as the indication for PCI. Multivariable logistic regression analysis was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in patients with CLD compared with those without CLD. Among 7,296,679 PCI admissions, 54,368 (0.7%) had a CLD diagnosis. Among patients with CLD, 36,853 (67.8%) had severe CLD. Patients with CLD had higher likelihood of adverse outcomes including major adverse cardiovascular and cerebrovascular events (MACCE) (aOR 1.25, 95%CI 1.20 to 1.30), mortality (aOR 1.43, 95%CI 1.35 to 1.51), major bleeding (aOR 2.22, 95%CI 2.12 to 2.32). When accounting for severity, only severe CLD subgroup was more likely to have MACCE and all-cause mortality compared to no-CLD patients (p <0.001). Among CLD etiologic subgroups, those with 'alcohol-related liver disease' and 'other CLD' were consistently more likely to develop MACCE, all-cause mortality and major bleeding in comparison to no-CLD patients, while 'chronic viral hepatitis' subgroup had only increased odds of major bleeding (p <0.001). In conclusion, CLD patients admitted for PCI are more likely to have worse in-hospital outcomes, particularly in the severe CLD subgroup and 'alcohol-related liver disease' and 'other CLD' etiologic subgroups.

A meta-analysis and cost-minimization analysis of bivalirudin versus heparin in high-risk patients for percutaneous coronary intervention

This meta‐analysis was performed to compare the safety, efficacy, and pharmacoeconomic of bivalirudin versus heparin in high‐risk patients for percutaneous coronary interventions (PCI). Earlier meta‐analysis comparing bivalirudin and heparin during PCI demonstrated that bivalirudin caused less bleeding with more stent thrombosis. However, little data were available on the safety of bivalirudin versus heparin in high‐risk patients for PCI. Thus, we performed a meta‐analysis to evaluate the efficacy and safety in the “high‐risk” patients. A systematic search of electronic databases was conducted up to July 30, 2020. The Cochrane Risk of Bias assessment tool was used to assess the quality of included studies. The primary outcomes were all‐cause death and major adverse cardiac events (MACE); secondary outcomes were major and minor bleeding, followed by a cost‐minimization analysis comparing bivalirudin and heparin using a local drug and medical costs reported in China. Subgroup analysis was based on the type of disease of the high‐risk population. Finally, a total of 10 randomized controlled trials involved 42,699 patients were collected. The Cochrane Risk of Bias Tool was employed to appraise the research quality. No significant difference was noted between bivalirudin and heparin regarding all‐cause death and MACE. However, subgroup analysis showed that bivalirudin caused less major bleeding in female (OR:0.65, 95% CI:0.53–0.79), diabetes (OR:0.55, 95%CI:0.42–0.73), and CKD (OR:0.59, 95%CI:0.63–1.65). The scatterers of the included literature were approximately symmetrical, and no research was outside the funnel plot. Additionally, cost‐minimization analysis showed that heparin was likely to represent a cost‐effective option compared with bivalirudin in China, with potential savings of 2129.53 Chinese Yuan (CNY) per patient for one PCI. Overall, the meta‐analysis showed that although bivalirudin appeared to have a lower risk of major bleeding rate, the overall effectiveness and safety between the two groups showed no significant difference in high‐risk patients for PCI. But the results of the cost‐minimization analysis showed that heparin could be a potential cost‐saving drug than bivalirudin in patients for PCI in China.

Anemia is a novel predictor for clinical ISR following PCI

Background

Conflicting data were found regarding the anemia’s effect on percutaneous coronary intervention (PCI) outcomes. We directed our study to investigate anemia’s effect on clinical in-stent restenosis (ISR) following PCI.

Results

A prospective multi-center cohort study was performed on 470 consecutive participants undergoing elective PCI. We classified the participants into two groups: group 1 who were anemic and group 2 who were non-anemic as a control group. At 1, 3, 6, and 12 months by clinic visits, we followed up with the patients to assess anemia’s clinical ISR effect. We found that 20% of the patients undergoing PCI had anemia. Anemic patients showed a statistically significant higher rate of impaired renal function and diabetes and a higher percentage of the female gender. Multivariate regression analysis for major adverse cardiovascular events (MACEs) after adjusting for confounding factors revealed that anemia represents a more risk on MACE (adjusted hazard ratio (HR) was 4.13; 95% CI 2.35–7.94; p value < 0.001) and carries a higher risk upon clinical ISR (adjusted HR was 3.51; 95% CI 1.88–7.16; p value < 0.001) over 12 months of follow-up.

Conclusion

Anemic patients going through PCI are generally females, diabetics, and have renal impairment. Anemia might be considered another indicator for clinical ISR and is fundamentally associated with an increased MACE incidence.

Red blood cell transfusion threshold and mortality in cardiac intensive care unit patients

BACKGROUND

The benefit of red blood cell (RBC) transfusion in anemic critically-ill patients with cardiovascular disease is uncertain, as is the optimal threshold at which RBC transfusion should be considered. We sought to examine the association between RBC transfusion and mortality stratified by nadir Hgb level and admission diagnosis among cardiac intensive care unit (CICU) patients.

METHODS

Retrospective single-center cohort of 11,754 CICU patients admitted between 2007 and 2018. The association between RBC transfusion and hospital mortality at each nadir Hgb (<8 g/dL, 8-9.9 g/dL, ≥10 g/dL) was assessed using multivariable logistic regression adjusted for the propensity to receive RBC transfusion.

RESULTS

The study population had a mean age of 68±15 years, including 38% females; 1,134 (11.4%) received RBC transfusion. Admission diagnoses included: acute coronary syndrome , 42%; heart failure, 50%; cardiac arrest , 12%; and cardiogenic shock , 12%. Patients who received RBC transfusion had higher crude hospital mortality (19% vs. 8%, P<.001). RBC transfusion was associated with lower adjusted hospital mortality in patients with nadir Hgb <8 g/dL after propensity adjustment, including subgroups with acute coronary syndrome, cardiac arrest, or cardiogenic shock (all P <.01). RBC transfusion was not associated with lower adjusted hospital mortality in any subgroup of patients with nadir Hgb ≥8 g/dL.

CONCLUSIONS

These observational data suggest the use of a Hgb threshold <8 g/dL for RBC transfusion in most CICU patients, although we could not exclude a potential benefit of RBC transfusion at a nadir Hgb of 8 to 9.9 g/dL; we did not observe any benefit from RBC transfusion at a nadir Hgb ≥10 g/dL.

Ischemic/bleeding event after short dual-antiplatelet therapy in patients with high bleeding risk: Sub-analysis of the MODEL U-SES study

BACKGROUND

This analysis aimed to evaluate the clinical impact of high bleeding risk (HBR) on adverse events after percutaneous coronary intervention (PCI).

METHODS

We retrospectively analyzed 1695 patients in the MODEL U-SES study, which was a multicenter, open-label, prospective observational study evaluating safety of 3-month dual antiplatelet therapy (DAPT) after Ultimaster stent (Terumo Corporation, Tokyo, Japan) implantation at 65 sites in Japan. Patients were divided into 2 groups (HBR/Non-HBR) according to modified Academic Research Consortium-HBR criteria. Ischemic/thrombotic event (cardiovascular death, myocardial infarction, ischemic stroke, and stent thrombosis) and bleeding event (Bleeding Academic Research Consortium 3 or 5) at 1 year were evaluated.

RESULTS

Of 1695 patients, 840 patients were categorized as HBR and 855 patients were Non-HBR. One-year follow-up was completed in 95.3%. During 1-year follow-up, ischemic/thrombotic events were observed in 31 cases (1.8%) and bleeding events occurred in 21 cases (1.2%). Presence of HBR was significantly associated with higher incidence of ischemic/thrombotic events as compared to Non-HBR (adjusted hazard ratio, 0.16; 95% confidence interval, 0.05 to 0.50), whereas the incidence of bleeding events did not reach statistical significance between HBR and Non-HBR. In comparison of monotherapy after DAPT, P2Y₁₂ inhibitor monotherapy after DAPT had comparable ischemic/thrombotic and bleeding events with aspirin monotherapy after DAPT in both HBR and Non-HBR.

CONCLUSION

In contemporary PCI practice, nearly half of patients had HBR and presence of HBR significantly increased risk of ischemic/thrombotic events. Both aspirin and P2Y₁₂ inhibitor monotherapy following short DAPT had low and comparable ischemic/bleeding events.

Predictors of incident heart failure in a cohort of patients with ischemic heart disease

INTRODUCTION

heart failure (HF) is a major complication following ischemic heart disease (IHD) and it adversely affects the outcome. The objective of this study was to identify predictors of HF in patients with IHD.

METHODS

this is a 24-month longitudinal retrospective study of all consecutive patients diagnosed with IHD. Endpoints were incident HF and time to incident HF. Patients with a previous history of HF were excluded.

RESULTS

a total of 306 patients with IHD were included in the analysis. The 6-month, 12-month and 18-month cumulative risk of developing incident HF were 18.8%, 28.4%, and 53.5% respectively. Increasing age, female gender, diabetes mellitus (DM), lower hemoglobin, and dilated left atrium were strong predictors of incident HF. Predictors of shorter time to incident HF were coexisting DM and hypertension, and the presence of dilated left atrium in patients with left ventricular ejection fraction < 40%. The strongest predictor of incident HF in patients with DM was a higher level of LDL cholesterol.

CONCLUSION

patients with IHD have a higher risk of incident HF. Strong predictors of incident HF in these patients were increasing age, female gender, DM, lower hemoglobin and dilated left atrium. Such patients need close follow-up and more intensive treatment.

Association of the Hemoglobin to Serum Creatinine Ratio with In-Hospital Adverse Outcomes after Percutaneous Coronary Intervention among Non-Dialysis Patients: Insights from a Japanese Nationwide Registry (J-PCI Registry)

Although baseline hemoglobin and renal function are both important predictors of adverse outcomes after percutaneous coronary intervention (PCI), scarce data exist regarding the combined impact of these factors on outcomes. We sought to investigate the impact and threshold value of the hemoglobin to creatinine (Hgb/Cr) ratio, on in-hospital adverse outcomes among non-dialysis patients in a Japanese nationwide registry. We analyzed 157,978 non-dialysis patients who underwent PCI in 884 Japanese medical institutions in 2017. We studied differences in baseline characteristics and in-hospital clinical outcomes among four groups according to their quartiles of the Hgb/Cr ratios. Compared with patients with higher Hgb/Cr ratios, patients with lower ratios were older and had more comorbidities and complex coronary artery disease. Patients with lower hemoglobin and higher creatinine levels had a higher rate of in-hospital adverse outcomes including in-hospital mortality and procedural complications (defined as occurrence of cardiac tamponade, cardiogenic shock after PCI, emergency operation, or bleeding complications that required blood transfusion). On multivariate analyses, Hgb/Cr ratio was inversely associated with in-hospital mortality (odds ratio: 0.91, 95% confidence interval: 0.89–0.92; p < 0.001) and bleeding complications (odds ratio: 0.92, 95% confidence interval: 0.90–0.94; p < 0.001). Spline curve analysis demonstrated that these risks started to increase when the Hgb/Cr ratio was <15, and elevated exponentially when the ratio was <10. Hgb/Cr ratio is a simple index among non-dialysis patients and is inversely associated with in-hospital mortality and bleeding complications after PCI.

Long-term impact of baseline anaemia on clinical outcomes following percutaneous coronary intervention in stable angina

BACKGROUND

In patients with stable angina (SA), the clinical benefits of percutaneous coronary intervention (PCI) reside almost exclusively within the realm of symptomatic improvement rather than improvement in hard clinical endpoints. The benefits of PCI should always be balanced against its potential short-term and long-term risks. Common among these risks is the presence of anaemia and its interaction with poor clinical outcomes and increased morbidity; this study aims to elucidate the impact of anaemia on long-term clinical outcomes of this patient group.

METHODS

From Danish national registries, we identified patients with SA treated with PCI who had a haemoglobin measurement maximum of 90 days prior to PCI procedure. Anaemia was defined as haemoglobin <130 and <120 g/L in men and women, respectively. Follow-up was up to 3 years after PCI, and Cox regression was used to estimate HRs with 95% CIs of hospitalisation due to bleeding, acute coronary syndrome (ACS) and all-cause mortality in patients with anaemia compared with patients without anaemia.

RESULTS

Of 2837 included patients, 14.6% had anaemia prior to PCI. During follow-up, 93 patients (3.3%) had a bleeding episode, which was higher in patients with anaemia (5.8%) compared with patients without anaemia (2.8%). A total of 213 patients (7.5%) developed ACS, which was higher in patients with anaemia (10.6%) compared with patients without anaemia (7.0%). Furthermore, 185 patients (6.5%) died, with a mortality rate of 18.1% in patients with anaemia compared with 4.5% in patients without anaemia. In multivariable analyses, anaemia was associated with a significantly increased risk of bleeding (HR 1.69; 95% CI 1.04 to 2.73; P 0.033), ACS (HR 1.47; 95% CI 1.04 to 2.10; P 0.031) and all-cause mortality (HR 2.41; 95% CI 1.73 to 3.30; P <0.001).

CONCLUSION

Anaemia in patients with SA was significantly associated with bleeding, ACS and all-cause mortality following PCI.

Validation of the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria in patients undergoing percutaneous coronary intervention and comparison with contemporary bleeding risk scores

AIMS

The Academic Research Consortium for High Bleeding Risk (ARC-HBR) defined consensus-based criteria for patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI). We aimed to validate the ARC-HBR criteria for the bleeding outcomes using a large cohort of patients undergoing PCI.

METHODS AND RESULTS

Between 2009 and 2016, patients undergoing PCI were prospectively included in the Bern PCI Registry. Patients were considered to be at HBR if at least one major criterion or two minor criteria were met. The primary endpoint was Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding at one year; ischaemic outcomes were assessed using the device-oriented composite endpoints (DOCE) of cardiac death, target vessel myocardial infarction, and target lesion revascularisation. Among 12,121 patients, those at HBR (n=4,781, 39.4%) had an increased risk of BARC 3 or 5 bleeding (6.4% vs 1.9%; p<0.001) and DOCE (12.5% vs 6.1%; p<0.001) compared with those without HBR. The degree of risk and prognostic value were related to the risk factors composing the criteria. The ARC-HBR criteria had higher sensitivity than the PRECISE-DAPT score and the PARIS bleeding risk score (63.8%, 53.1%, 31.9%), but lower specificity (62.7%, 71.3%, 86.5%) for BARC 3 or 5 bleeding.

CONCLUSIONS

Patients at HBR defined by the ARC-HBR criteria had a higher risk of BARC 3 or 5 bleeding as well as DOCE. The bleeding risk was related to its individual components. The ARC-HBR criteria were more sensitive for identifying patients with future bleedings than other contemporary risk scores at the cost of specificity. ClinicalTrials.gov Identifier: NCT02241291

Prognostic value of red cell distribution width in patients undergoing percutaneous coronary intervention: a meta-analysis

OBJECTIVE

To evaluate the prognostic value of baseline red cell distribution width (RDW) in patients with coronary artery diseases (CADs) undergoing percutaneous coronary intervention (PCI) by conducting a meta-analysis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

PubMed, Embase, Wanfang, CNKI and VIP databases were searched from their inceptions to 19 June 2019.

ELIGIBLE CRITERIA

Studies investigating the value of baseline RDW for predicting all-cause mortality, cardiovascular mortality and major adverse cardiac events (MACEs) in patients with CAD undergoing PCI were included.

DATA EXTRACTION AND SYNTHESIS

Two authors independently extracted the data and evaluated the methodological quality using the Newcastle-Ottawa Scale. STATA V.12.0 software was applied to produce the forest plots using a random-effect model.

RESULTS

Twelve studies (13 articles) involving 17 113 patients were included and analysed. Comparison between the highest and lowest RDW category indicated that the pooled risk ratio (RR) was 1.77 (95% CI 1.32 to 2.37) for all-cause mortality, 1.70 (95% CI 1.25 to 2.32) for cardiovascular mortality and 1.62 (95% CI 1.21 to 2.18) for MACEs. The predictive effect of elevated RDW for all-cause mortality was stronger in the subgroup of patients without anaemia (RR 4.59; 95% CI 3.07 to 6.86) than with anaemia.

CONCLUSIONS

This meta-analysis indicated that elevated RDW was associated with higher risk of mortality and adverse cardiac events in patients with CAD undergoing PCI. The value of elevated RDW for predicting all-cause mortality appears to be stronger in patients without anaemia. RDW may be served as a promising prognostic biomarker in patients undergoing PCI.

Relative Efficacies of HBOC-201 and Polyheme to Increase Oxygen Transport Compared to Blood and Crystalloids

BACKGROUND

Because total hemoglobin in circulation ([THb]) is an established predictor of clinical outcomes in anemic individuals, the relative efficacies of resuscitation fluids to increase [THb] can be used to design better hemoglobin-based oxygen carrier (HBOC) clinical trials.

METHODS

Expected efficacies of HBOC-201 (13 g Hb/dL) and packed red blood cells (RBCs) (packed red blood cells [pRBCs], 24 g Hb/dL) to increase [THb] were calculated and interpreted in the context of severe adverse events (SAEs) in the HEM-0115 phase III clinical trial.The PolyHeme phase III clinical trial compared the HBOC, PolyHeme (10 g Hb/dL), with crystalloid control prehospital and packed RBCs in hospital. The comparative abilities of these resuscitation fluids to maintain [THb] were interpreted in the context of mortality.

RESULTS

In HEM-0115, infusion of HBOC-201 increased [THb] by 0.18 ± 0.03 g/dL (N=121) compared with 0.87 ± 0.07 g/dL (n = 115) following one unit of pRBCs. These observed increases in [THb] were similar to expected increases for these fluids. Use of HBOC-201 was associated with 0.34 SAEs per patient compared with 0.25 SAEs per patient in the pRBC arm (P = 0.016).Hemoglobin Deficit was greater in HBOC-201-treated patients than in pRBC controls and emerged as a predictor of SAEs in a logistics model. Randomization to HBOC-201 had no power to predict SAEs.PolyHeme more effectively maintained [THb] than did crystalloid prior to arrival at hospital, associated with initially higher survival in the PolyHeme arm. Thereafter, PolyHeme subjects sustained lower [THb] and higher mortality than controls.

CONCLUSION

Greater anemia in subjects randomized to HBOC-201 was consistent with the relative efficacies of HBOC-201 and pRBCs to increase [THb] and may have contributed to more SAEs in the HBOC arm of HEM-0115 and greater long-term mortality in the PolyHeme trial.

Acute myocardial infarction treatments and outcomes in 6.5 million patients with a current or historical diagnosis of cancer in the USA

Aims

The aim of this study is to evaluate temporal trends, treatment, and clinical outcomes of patients who present with an acute myocardial infarction (AMI) and have a current or historical diagnosis of cancer, according to cancer type and presence of metastases.

Methods and results

Data from 6 563 255 patients presenting with an AMI between 2004 and 2014 from the US National Inpatient Sample (NIS) database were analysed. A total of 5 966 955 had no cancer, 186 604 had current cancer, and 409 697 had a historical diagnosis of cancer. Prostate, breast, colon, and lung cancer were the four most common types of cancer. Patients with cancer were older with more comorbidities. Differences in invasive treatment were noted, 43.9% received percutaneous coronary intervention (PCI) in patients without cancer, whilst only 21.0% of patients with lung cancer received PCI. Lung cancer was associated with the highest in-hospital mortality [odds ratio (OR) 2.71, 95% confidence interval (CI) 2.62–2.80], major adverse cardiovascular and cerebrovascular complications (OR 2.38, 95% CI 2.31–2.45), and stroke (OR 1.91, 95% CI 1.80–2.02), while colon cancer was associated with highest risk of bleeding (OR 2.82, 95% CI 2.68–2.98). Irrespective of the type of cancer, presence of metastasis was associated with worse in-hospital outcomes, and historical cancer did not adversely impact on survival (OR 0.90, 95% CI 0.89–0.91).

Conclusion

A concomitant cancer diagnosis is associated with a conservative medical management strategy for AMI, and worse clinical outcomes, compared to patients without cancer. Survival and clinical outcomes in the context of AMI vary significantly according to the type of cancer and metastasis status. The management of this high-risk group is challenging and requires a multidisciplinary and patient-centred approach to improve their outcomes.

A case study of 10 patients administered HBOC-201 in high doses over a prolonged period: outcomes during severe anemia when transfusion is not an option

BACKGROUND

Hemoglobin-Based Oxygen Carriers (HBOCs) can act as an "oxygen bridge" in acute severe anemia when transfusion is indicated, but not possible. We present data on 10 Expanded Access (EA) patients treated with high cumulative doses of Hemopure (HBOC-201), to assess the ability of HBOC-201 to safely treat life threatening anemia in situations where high volumes of product were administered over an extended period of time.

STUDY DESIGN AND METHODS

Inclusion in this study required that the patient receive at least 10 units of HBOC-201 between 2014 and 2017 under the FDA-sanctioned EA program. Depending on a patient's geographical location, treatment with HBOC-201 was obtained through either a single patient emergency Investigational New Drug (IND) application, or an intermediate size population IND. Of the 41 patients who were treated during this period, 10 patients received 10 or more units of the product. Data were obtained from medical records.

RESULTS

Treatments with HBOC-201 started within 24 hours of signing consent and were administered at an average rate of 1.99 (SD 0.17) units per day over a mean of 8.2 days (SD 2.9), during which patients received on average 16.2 units (SD 5.7 units) of HBOC-201. The median pre-treatment nadir corpuscular hemoglobin (Hb) concentration was 3.3 (SD 0.9) g/dL and post-treatment Hemoglobin was 7.3 (SD 1.7) g/dL. Common side effects included methemoglobinemia, gastrointestinal symptoms, and hypertension. However, no product-related serious adverse events (SAEs) were noted. All patients survived.

CONCLUSIONS

Administration of HBOC-201 over an extended period is a feasible and safe oxygen bridge for severely anemic patients who cannot be transfused with RBC.

Impact of Anemia on the Risk of Bleeding Following Percutaneous Coronary Interventions in Patients ≥75 Years of Age

Bleeding risk stratification is an unresolved issue in older adults. Anemia may reflect subclinical blood losses that can be exacerbated after percutaneous coronary intervention . We sought to prospectively determine the contribution of anemia to the risk of bleeding in 448 consecutive patients aged 75 or more years, treated by percutaneous coronary interventions without concomitant indication for oral anticoagulation. We evaluated the effect of WHO-defined anemia on the incidence of 1-year nonaccess site-related major bleeding. The prevalence of anemia was 39%, and 13.1% of anemic and 5.2% of nonanemic patients suffered a bleeding event (hazard ratio 2.75, 95% confidence interval 1.37 to 5.54, p = 0.004). Neither PRECISE-DAPT nor CRUSADE scores were superior to hemoglobin for the prediction of bleeding. In conclusion, anemia is a powerful predictor of bleeding with potential utility for simplifying tailoring therapies.

Anemia as an independent predictor of adverse outcomes after carotid revascularization

BACKGROUND

Anemia has been identified as a risk factor for postoperative morbidity and mortality after major vascular procedures. Carotid revascularization carries less cardiac morbidity and physiologic stress compared with other vascular interventions. This study evaluated the association between preoperative anemia and major adverse events after carotid revascularization.

METHODS

Patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) between January 2012 and June 2018 in the Vascular Quality Initiative database were identified. Anemia was defined as a preoperative hemoglobin level of <12 g/dL in women and <13 g/dL in men. Multivariable logistic analysis and 1:1 coarsened exact matching were used to study the association between preoperative anemia and in-hospital major adverse cardiac events (MACEs), defined as a composite of stroke, death, and myocardial infarction, and between anemia and 30-day mortality after CEA and CAS.

RESULTS

Of 102,719 patients included in the analysis, 34.8% were anemic (CEA, 34.1%; CAS, 37.8%; P < .001). Anemic patients were older and had more medical comorbidities compared with nonanemic patients. In-hospital MACEs (2.8% vs 1.9%; P < .001) and 30-day mortality (0.9% vs 0.4%; P < .001) were higher among anemic patients. On multivariable analysis, anemia was associated with 18% higher odds of in-hospital MACEs (odds ratio, 1.18; 95% confidence interval, 1.07-1.31, P = .001) and 74% higher odds of 30-day mortality (odds ratio, 1.74; 95% confidence interval, 1.40-2.17, P < .001). Coarsened exact matching showed similar results. The association between preoperative anemia and adverse outcomes was similar in both CAS and CEA and in symptomatic and asymptomatic patients (P interaction > .05).

CONCLUSIONS

Anemia is associated with increased odds of adverse events after CEA and CAS. It should be factored into the preoperative risk assessment of patients undergoing carotid revascularization. Prospective studies are needed to study the effectiveness of correcting low preoperative hemoglobin levels in these patients and the association between anemia and long-term outcomes after CEA and CAS.

Association between red blood cell distribution width and long-term mortality among patients undergoing percutaneous coronary intervention with previous history of cancer

Background: The number of patients suffering from coronary heart disease with cancer is rising. There is scarce evidence concerning the biomarkers related to prognosis among patients undergoing percutaneous coronary intervention (PCI) with cancer. Thus, the aim of this study was to investigate the association between red blood cell distribution width (RDW) and prognosis in this population.Methods: A total of 172 patients undergoing PCI with previous history of cancer were enrolled in this retrospective study. The endpoint was long-term all-cause mortality. According to tertiles of RDW, the patients were classified into three groups: Tertile 1 (RDW <12.8%), Tertile 2 (RDW ≥12.8% and <13.5%) and Tertile 3 (RDW ≥13.5%).Results: During an average follow-up period of 33.3 months, 29 deaths occurred. Compared with Tertile 3, mortality of Tertile 1 and Tertile 2 was significantly lower in the Kaplan-Meier analysis. In multivariate Cox regression analysis, RDW remained an independent risk factor of mortality (HR: 1.938, 95% CI: 1.295-2.655, p < 0.001). The all-cause mortality in Tertile 3 was significantly higher than that in Tertile 1 (HR: 5.766; 95% CI: 1.426-23.310, p = 0.014).Conclusions: An elevated RDW level (≥13.5%) was associated with long-term all-cause mortality among patients undergoing PCI with previous history of cancer.

Increased risk of cardiovascular mortality by strict glycemic control (pre-procedural HbA1c < 6.5%) in Japanese medically-treated diabetic patients following percutaneous coronary intervention: a 10-year follow-up study

BACKGROUND

In the secondary prevention of cardiovascular (CV) disease in patients with diabetes, an optimal level of HbA1c, the most widely-used glycemic control indicator, for favorable clinical consequences still remains to be established. This study assessed the association between preprocedural HbA1c level and CV mortality in Japanese diabetic patients undergoing percutaneous coronary intervention (PCI).

METHODS

This is a retrospective observational study using a single-center prospective PCI database involving consecutive 4542 patients who underwent PCI between 2000 and 2016. Patients with any antidiabetic medication including insulin at PCI were included in the analysis (n = 1328). We divided the patients into 5 and 2 groups according to HbA1c level; HbA1c: < 6.5% (n = 267), 6.5-7.0% (n = 268), 7.0-7.5% (n = 262), 7.5-8.5% (n = 287) and ≥ 8.5% (n = 244), and 7.0% > and ≤ 7.0%, respectively. The primary outcome was CV mortality including sudden death. The median follow-up duration was 6.2 years.

RESULTS

In the follow-up period, CV and sudden death occurred in 81 and 23 patients, respectively. While unadjusted Kaplan-Meier analysis showed no difference in cumulative CV mortality rate between patients binarized by preprocedural HbA1c 7.0%, analysis of the 5 groups of HbA1c showed significantly higher cumulative CV death in patients with HbA1c < 6.5% compared with those with 7.0-7.5% (P = 0.042). Multivariate Cox hazard analysis revealed a U-shaped relationship between preprocedural HbA1c level and risk of CV death, and the lowest risk was in the HbA1c 7.0-7.5% group (Hazard ratio of HbA1c < 6.5% compared to 7.0-7.5%: 2.97, 95% confidence interval: 1.33-7.25, P = 0.007). Similarly, univariate analysis revealed the lowest risk of sudden death was in the HbA1c 7.0-7.5% group.

CONCLUSION

The findings indicate an increased risk of CV mortality by strict glycemic control (HbA1c < 6.5%) in the secondary prevention of CV disease in Japanese patients with medically-treated diabetes. Trial registration This study reports the retrospective analysis of a prospective registry database of patients who underwent PCI at Juntendo University Hospital, Tokyo, Japan (Juntendo Physicians' Alliance for Clinical Trials, J-PACT), which is publicly registered (University Medical Information Network Japan-Clinical Trials Registry UMIN-CTR 000035587).

Outcomes of percutaneous coronary interventions in cancer patients

Introduction: There are numerous shared risk factors in the etiopathogenesis of coronary artery disease (CAD) and cancer both at epidemiologic and molecular level. Additionally, different modalities of treatment of cancer such as radiation, chemotherapy, immunotherapy, and hormonal therapies further increase the risk of CAD and acute coronary syndrome. Most large database analysis and single-center experiences have shown that cancer patients undergoing PCI are at an increased risk of in-hospital mortality, bleeding, repeat revascularization.Areas covered: In this review article the authors discuss the associations between CAD and cancer, challenges for PCI in cancer patients and outcome data.Expert opinion: Interventionists performing PCI on cancer patients should be cognizant of the heightened risk of bleeding, thrombosis, possible need for interruption of dual-antiplatelet therapy, and the increased risk of target lesion revascularization in this cohort. These risks may be partially mitigated by utilization of best practices such as the use of radial artery access, intravascular imaging for lesion assessment and stent optimization and avoidance of complex stenting strategies. Finally, it is of paramount importance to have a multidisciplinary approach consisting of the treating cardiologist, medical and/or surgical oncologist, and palliative medicine, and involve the patient and their family in making informed decisions.

Impact of hemoglobin concentration and platelet count on outcomes of patients with non-valvular atrial fibrillation: A subanalysis of the J-RHYTHM Registry

BACKGROUND

To clarify the influence of hemoglobin concentration and platelet count on adverse outcomes of Japanese patients with non-valvular atrial fibrillation (NVAF), a post hoc analysis of the J-RHYTHM Registry was performed.

METHODS

A consecutive series of outpatients with atrial fibrillation were enrolled from 158 institutions and followed up for 2 years or until an event occurred (thromboembolism, major hemorrhage, or all-cause death). Among 7406 patients with NVAF, 6536 with complete blood count data (69.8 ± 9.9 years, 71.0% men) were divided into 4 groups according to the baseline hemoglobin level (<10.0, 10.0-11.9, 12.0-13.9, and ≥14.0 g/dL) or platelet count (<10.0, 10.0-19.9, 20.0-29.9, and ≥30.0 × 10⁴/μL).

RESULTS

Incidence rates of major hemorrhage (p = 0.004 for trend), all-cause death (p < 0.001 for trend), and composite events (p < 0.001 for trend) increased as hemoglobin levels decreased, and composite events (p = 0.045 for trend) increased as platelet counts decreased. After adjusting for multiple confounders, the incidence of all-cause death and composite events was higher with hemoglobin levels <12.0 g/dL than a hemoglobin level ≥14.0 g/dL. In contrast, platelet count was not associated with any events. This was also true when multivariate analysis was performed using the stepwise forward method.

CONCLUSIONS

A low hemoglobin level (<12.0 g/dL) was an independent risk factor for all-cause death and composite events in Japanese patients with NVAF. However, platelet count did not impact outcomes.

CLINICAL TRIAL REGISTRATION

http://www.umin.ac.jp/ctr/ (unique identifier: UMIN000001569).

Prognostic Impact of Baseline Hemoglobin Levels on Long-Term Thrombotic and Bleeding Events After Percutaneous Coronary Interventions

Background

Association of baseline hemoglobin levels with long‐term adverse events after percutaneous coronary interventions has not been yet thoroughly defined. We aimed to assess the clinical impact of baseline hemoglobin on long‐term ischemic and bleeding risk after percutaneous coronary intervention.

Methods and Results

Using the pooled individual patient‐level data from the 3 percutaneous coronary intervention studies, we categorized 19 288 patients into 4 groups: high‐normal hemoglobin (≥14.0 g/dL; n=7555), low‐normal hemoglobin (13.0–13.9 g/dL in men and 12.0–13.9 g/dL in women; n=5303), mild anemia (11.0–12.9 g/dL in men and 11.0–11.9 g/dL in women; n=4117), and moderate/severe anemia (<11.0 g/dL; n=2313). Median follow‐up duration was 3 years. Low‐normal hemoglobin, mild anemia, and moderate/severe anemia correlated with significant excess risk relative to high‐normal hemoglobin for GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries Trial) moderate/severe bleeding, with adjusted hazard ratios of 1.22 (95% CI, 1.04–1.44), 1.73 (95% CI, 1.47–2.04), and 2.31 (95% CI, 1.92–2.78), respectively. Moderate/severe anemia also correlated with significant excess risk relative to high‐normal hemoglobin for the ischemic composite end point of myocardial infarction/ischemic stroke (adjusted hazard ratio, 1.33; 95% CI, 1.11–1.60), whereas low‐normal hemoglobin and mild anemia did not. However, the excess risk of low‐normal hemoglobin, mild anemia, and moderate/severe anemia relative to high‐normal hemoglobin remained significant for ischemic stroke and for mortality.

Conclusions

Decreasing baseline hemoglobin correlated with incrementally higher long‐term risk for major bleeding, ischemic stroke, and mortality after percutaneous coronary intervention. Even within normal range, lower baseline hemoglobin level correlated with higher ischemic and bleeding risk.

Relation of Preprocedural Hemoglobin Level to Outcomes After Percutaneous Coronary Intervention

Adverse effects have been reported in patients with preprocedural anemia after percutaneous coronary intervention (PCI), but data regarding the relation between elevated hemoglobin (Hb) level and post-PCI prognosis remain limited. This study assessed the impact of elevated Hb on major adverse cardiac and cerebrovascular event (MACCE) at 12 months, a composite of all-cause mortality, nonfatal myocardial infarction, and ischemic stroke after PCI. We pooled patient-level data from four Korean multicenter drug-eluting stent registries from 2010 to 2016. In total, 5,107 patients were divided into 5 categories according to the baseline Hb level (<10, 10 to 12.9, 13 to 14.9, 15 to 16.9 and ≥17 g/dl). Patients with higher Hb levels were significantly younger, predominantly male, current smokers with higher body mass index, and more frequent dyslipidemia. Hypertension, diabetes, chronic kidney disease, and cerebrovascular accident were more prevalent in lower Hb groups. Categorically, a U-shaped curvilinear relation was observed between baseline Hb and clinical outcomes showing significantly higher MACCE rate in <10g/dl (hazard ratio [HR], 4.62 [2.81 to 7.68]) and ≥17 g/dl (HR, 4.06 [1.57 to 10.5]) groups compared with the reference group (13 to 14.9 g/dl), especially in men. In nonanemic patients (Hb ≥13 g/dl), adjusted HRs of MACCE, mortality, and stroke were significantly higher in ≥17 g/dl group than in the reference group. Furthermore, ≥17 g/dl was an independent predictor for MACCE and all-cause mortality after PCI. In conclusion, not only low Hb but also elevated Hb of ≥17 g/dl was significantly associated with higher MACCE rates and all-cause mortality after PCI. An appropriate treatment strategy for patients with high Hb level should be identified through future studies.

Association between anemia and hematological indices with mortality among cardiac intensive care unit patients

Background

Anemia and elevated red cell distribution width (RDW) or mean corpuscular volume (MCV) are associated with an adverse prognosis in patients with cardiovascular disease and critical illness. Limited data exist regarding these associations in unselected cardiac intensive care unit (CICU) patients.

Methods

Retrospective cohort study of CICU patients between January 1, 2007, and December 31, 2015, with a hemoglobin (Hb) level measured at admission. Multivariable regression was performed to determine predictors of hospital mortality, and Kaplan–Meier analysis was used to determine post-discharge survival.

Results

We included 9644 patients with a mean age of 67.5 ± 15.1 years, including 3604 (37.4%) females. The median (IQR) values of Hb, MCV and RDW were 12.2 g/dL (10.6, 13.7), 90.7 fL (87.3, 94.2) fL, and 14.1% (13.3, 15.8), respectively. Anemia (admission Hb < 12 g/dL) was present in 4434 (46%) patients. A total of 845 (8.8%) patients died in the hospital. Patients with anemia had higher hospital mortality (11.3% vs. 6.6%, unadjusted OR 1.82, 95% CI 1.58–2.10, p < 0.001). After multivariable regression, admission Hb and MCV were not significantly associated with hospital mortality (both p > 0.1), while admission RDW (adjusted OR 1.12 per 1%, 95% CI 1.07–1.18, p < 0.001) was significantly associated with hospital mortality. Hospital survivors with lower Hb, higher MCV, or higher RDW had lower post-discharge survival.

Conclusion

Elevated RDW on admission was independently associated with higher hospital mortality in CICU patients. These data emphasize the importance of hematologic abnormalities for mortality risk stratification in CICU populations.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s00392-019-01549-0) contains supplementary material, which is available to authorized users.

Defining high bleeding risk in patients undergoing percutaneous coronary intervention: a consensus document from the Academic Research Consortium for High Bleeding Risk

Identification and management of patients at high bleeding risk undergoing percutaneous coronary intervention are of major importance, but a lack of standardization in defining this population limits trial design, data interpretation, and clinical decision-making. The Academic Research Consortium for High Bleeding Risk (ARC-HBR) is a collaboration among leading research organizations, regulatory authorities, and physician-scientists from the United States, Asia, and Europe focusing on percutaneous coronary intervention-related bleeding. Two meetings of the 31-member consortium were held in Washington, DC, in April 2018 and in Paris, France, in October 2018. These meetings were organized by the Cardiovascular European Research Center on behalf of the ARC-HBR group and included representatives of the US Food and Drug Administration and the Japanese Pharmaceuticals and Medical Devices Agency, as well as observers from the pharmaceutical and medical device industries. A consensus definition of patients at high bleeding risk was developed that was based on review of the available evidence. The definition is intended to provide consistency in defining this population for clinical trials and to complement clinical decision-making and regulatory review. The proposed ARC-HBR consensus document represents the first pragmatic approach to a consistent definition of high bleeding risk in clinical trials evaluating the safety and effectiveness of devices and drug regimens for patients undergoing percutaneous coronary intervention.

Effect of Chronic Hematologic Malignancies on In-Hospital Outcomes of Patients With ST-Segment Elevation Myocardial Infarction

In view of hemorrhagic and prothrombotic tendencies, ST-segment elevation myocardial infarction (STEMI) patients with chronic hematologic malignancies (CHM) are felt to be at a higher risk and hence denied standard reperfusion strategies. In-hospital outcomes of CHM patients presenting with STEMI are unclear. The Nationwide Inpatient Sample data files from 2003 to 2014 were used to extract adult patients who presented with a primary diagnosis of STEMI. Patients who had a diagnosis of CHM defined as chronic myelogenous leukemia, chronic lymphocytic leukemia, essential thrombocythemia, polycythemia vera, chronic monocytic leukemia, and multiple myeloma were identified. The primary study outcome measure was in-hospital mortality. Inverse probability weighting-adjusted binary logistic regression was performed to identify independent predictors of in-hospital mortality. Of 2,715,807 STEMI patients included in the final analyses, 11,974 (0.4%) patients had a diagnosis of CHM. Patients with CHM were significantly older, had a higher prevalence of co-morbidities, and had a significantly higher unadjusted in-hospital mortality (14.9% vs 9.0%; p <0.001). After adjusting for co-morbidities, CHM did not independently predict a higher in-hospital mortality (odds ratio = 1.02, 95% confidence interval = 0.96 to 1.09; p = 0.461). In patients with CHM who presented with STEMI, percutaneous coronary intervention was found to be associated with a significant reduction in in-hospital mortality (odds ratio = 0.22, 95% confidence interval = 0.18 to 0.27; p <0.001) (c-statistic = 0.81). In conclusion, CHM patients presenting with STEMI should be treated with similar treatment strategies as those without CHM, including revascularization if indicated, as there appears to be a sizable outcome advantage with this approach.

Defining High Bleeding Risk in Patients Undergoing Percutaneous Coronary Intervention

Identification and management of patients at high bleeding risk undergoing percutaneous coronary intervention are of major importance, but a lack of standardization in defining this population limits trial design, data interpretation, and clinical decision-making. The Academic Research Consortium for High Bleeding Risk (ARC-HBR) is a collaboration among leading research organizations, regulatory authorities, and physician-scientists from the United States, Asia, and Europe focusing on percutaneous coronary intervention-related bleeding. Two meetings of the 31-member consortium were held in Washington, DC, in April 2018 and in Paris, France, in October 2018. These meetings were organized by the Cardiovascular European Research Center on behalf of the ARC-HBR group and included representatives of the US Food and Drug Administration and the Japanese Pharmaceuticals and Medical Devices Agency, as well as observers from the pharmaceutical and medical device industries. A consensus definition of patients at high bleeding risk was developed that was based on review of the available evidence. The definition is intended to provide consistency in defining this population for clinical trials and to complement clinical decision-making and regulatory review. The proposed ARC-HBR consensus document represents the first pragmatic approach to a consistent definition of high bleeding risk in clinical trials evaluating the safety and effectiveness of devices and drug regimens for patients undergoing percutaneous coronary intervention.

Meta-Analysis of Impact of Anemia and Hemoglobin Level on Survival After Transcatheter Aortic Valve Implantation

To establish evidence whether baseline anemia and decreases in baseline hemoglobin levels affect survival after transcatheter aortic valve implantation (TAVI), we performed a meta-analysis of available studies. Studies considered for inclusion met the following criteria: the design was a comparative study of patients with baseline anemia versus those without baseline anemia or a cohort study investigating baseline anemia (as a dichotomous variable) or baseline hemoglobin levels (as a continuous variable) as one of prognostic factors of mortality; the study population was patients who underwent TAVI; and main outcomes included early (30-day or in-hospital) or late (including early) all-cause mortality. Study-specific estimates were combined in the random-effects model. Our search identified 15 eligible studies including a total of 11,657 TAVI patients. Pooled analysis demonstrated that baseline anemia was associated with a statistically significant increase in early (p = 0.003) and midterm mortality (p < 0.0001) and that incremental decreases in baseline hemoglobin levels were associated with a statistically significant increase in midterm mortality (p < 0.00001). Pooled analysis of only adjusted estimates indicated that anemia was independently associated with a statistically significant increase in early (p = 0.02) and midterm mortality (p < 0.0001) and that incremental decreases in baseline hemoglobin levels were independently associated with a statistically significant increase in midterm mortality (p < 0.00001). In conclusion, baseline anemia and lower baseline hemoglobin levels may be associated with increased early and midterm mortality after TAVI.