Outcomes of Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

Sex-specific genetic risks for adverse outcomes after coronary revascularization procedures

Men and women have differing risks of adverse events after revascularization procedures and these differences could be partially driven by genetics. We studied the sex-specific differences in associations of polygenic risk scores (PRSs) with atrial fibrillation (AF), ischaemic stroke (STR), intracranial haemorrhage (ICH), myocardial infarction (MI) and gastrointestinal haemorrhage (GIH) in coronary revascularization patients. The study cohort comprised 5561 and 17 578 revascularized women and men. All participants underwent genotyping and register-based follow-up from 1961 to 2021. We calculated PRSs for all individuals and used Cox models with interaction term to examine the sex-specific associations between the PRSs and adverse outcomes after revascularization. The AF-PRS was more strongly associated with AF in men [hazard ratio (HR) per 1 standard deviation increase, 1.16; 95% confidence interval (CI), 1.12-1.19; P = 7.6 × 10-22) than in women (P for interaction 0.006). Conversely, ICH-PRS was more strongly associated with ICH after revascularization in women (HR, 1.32; 95% CI, 1.08-1.62; P = 0.008) than in men (P for interaction 0.008). We observed no sex-specific differences for the associations of PRSs with STR, MI or GIH. The genetic risk of AF after revascularization is greater in men than in women, and vice versa for ICH. Sex-specific PRSs could be used to identify individuals in high genetic risk for these complications.

In vitro evaluation of anticoagulant therapy management when urgent percutaneous coronary intervention is required in rivaroxaban-treated patients

We investigated in vitro the management of intraprocedural anticoagulation in patients requiring immediate percutaneous coronary intervention (PCI) while using regular direct oral anticoagulants (DOACs). Twenty-five patients taking 20 mg of rivaroxaban once daily comprised the study group, while five healthy volunteers included the control group. In the study group, a beginning (24 h after the last rivaroxaban dose) examination was performed. Then, the effects of basal and four different anticoagulant doses (50 IU/kg unfractionated heparin (UFH), 100 IU/kg UFH, 0.5 mg/kg enoxaparin, and 1 mg/kg enoxaparin) on coagulation parameters were investigated at the 4th and 12th h following rivaroxaban intake. The effects of four different anticoagulant doses were evaluated in the control group. The anticoagulant activity was assessed mainly by anti-factor Xa (anti-Xa) levels. Beginning anti-Xa levels were significantly higher in the study group than in the control group (0.69 ± 0.77 IU/mL vs. 0.20 ± 0.14 IU/mL; p < 0.05). The study group's 4th and 12th-h anti-Xa levels were significantly higher than the beginning level (1.96 ± 1.35 IU/mL vs. 0.69 ± 0.77 IU/mL; p < 0.001 and 0.94 ± 1.21 IU/mL vs. 0.69 ± 0.77 IU/mL; p < 0.05, respectively). Anti-Xa levels increased significantly in the study group with the addition of UFH and enoxaparin doses at the 4th and 12th h than the beginning (p < 0.001 at all doses). The safest anti-Xa level (from 0.94 ± 1.21 to 2.00 ± 1.02 IU/mL) was achieved 12 h after rivaroxaban with 0.5 mg/kg enoxaparin. Anticoagulant activity was sufficient for urgent PCI at the 4th h after rivaroxaban treatment, and additional anticoagulant administration may not be required at this time. Twelve hours after taking rivaroxaban, administering 0.5 mg/kg of enoxaparin may provide adequate and safe anticoagulant activity for immediate PCI. This experimental study result should confirm with clinical trials (NCT05541757).

Prognostic Impact of Atrial Fibrillation in Patients with Heavily Calcified Coronary Artery Disease Receiving Rotational Atherectomy

Background and Objectives: Although both rotational atherectomy (RA) and atrial fibrillation (AF) have a high thrombotic risk, there have been no previous studies on the prognostic impact of AF in patients who undergo percutaneous coronary intervention (PCI) using RA. Thus, the aim of the present study was to determine the prognostic impact of AF in patients undergoing PCI using RA. Materials and Methods: A total of 540 patients who received PCI using RA were enrolled between January 2010 and October 2019. Patients were divided into AF and sinus rhythm groups according to the presence of AF. The primary endpoint was net adverse clinical events (NACEs) defined as a composite outcome of all-cause death, myocardial infarction, target vessel revascularization, cerebrovascular accident, or total bleeding. Results: Although in-hospital adverse events showed no difference between those with AF and those without AF (in-hospital events, 54 (11.0%) vs. 6 (12.2%), p = 0.791), AF was strongly associated with an increased risk of NACE at 3 years (NACE: hazard ratio, 1.880; 95% confidence interval, 1.096-3.227; p = 0.022). Conclusions: AF in patients who underwent PCI using RA was strongly associated with poor clinical outcomes. Thus, more attention should be paid to thrombotic and bleeding risks.

Clinical utility of the BIWACO score for patients with atrial fibrillation after percutaneous coronary intervention

No predictive clinical risk scores for net adverse clinical events (NACE) have been developed for patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). We evaluated NACE to develop clinically applicable risk-stratification scores in the Bleeding and thrombotic risk evaluation In patients With Atrial fibrillation under COronary intervention (BIWACO) study, a multicenter survey which has enrolled a total of 7837 patients. We also investigated the current status and time trends for the use of antithrombotic drugs. A total of 188 AF patients who had received PCI were examined. At discharge, 65% of patients were prescribed a triple therapy (TT), 6% were prescribed a dual therapy, the remaining 29% of patients received dual-antiplatelet therapy. After 4 years, the fraction of patients continuing TT decreased by 15%, whereas oral anticoagulant alone was only 2% of patients. NACE developed in 20% of patients, resulting in death in 5% of the patients, and the remaining 13% experienced bleeding events. We developed risk scores for NACE comprising the five strongest predictive items, which we designated BIWACO scores. The area under the curve was 0.774 for NACE. Our study explored the differences in treatment practices and guideline recommendations for antithrombotic therapy. We concluded that our BIWACO score is useful for predicting clinical outcomes in AF-patients after PCI.

The Association of Sex with Unplanned Cardiac Readmissions following Percutaneous Coronary Intervention in Australia: Results from a Multicentre Outcomes Registry (GenesisCare Cardiovascular Outcomes Registry)

Background and aim: Unplanned cardiac readmissions in patients with percutaneous intervention (PCI) is very common and is seen as a quality indicator of in-hospital care. Most studies have reported on the 30-day cardiac readmission rates, with very limited information being available on 1-year readmission rates and their association with mortality. The aim of this study was to investigate the impact of biological sex at 1-year post-PCI on unplanned cardiac readmissions. Methods and results: Patients enrolled into the GenesisCare Cardiovascular Outcomes Registry (GCOR-PCI) from December 2008 to December 2020 were included in the study. A total of 13,996 patients completed 12 months of follow-up and were assessed for unplanned cardiac readmissions. All patients with unplanned cardiac readmissions in the first year of post-PCI were followed in year 2 (post-PCI) for survival status. The rate of unplanned cardiac readmissions was 10.1%. Women had a 29% higher risk of unplanned cardiac readmission (HR 1.29, 95% CI 1.11 to 1.48; p = 0.001), and female sex was identified as an independent predictor of unplanned cardiac readmissions. Any unplanned cardiac readmission in the first year was associated with a 2.5-fold higher risk of mortality (HR 2.50, 95% CI 1.67 to 3.75; p < 0.001), which was similar for men and women. Conclusion: Unplanned cardiac readmissions in the first year post-PCI was strongly associated with increased all-cause mortality. Whilst the incidence of all-cause mortality was similar between women and men, a higher incidence of unplanned cardiac readmissions was observed for women, suggesting distinct predictors of unplanned cardiac readmissions exist between women and men.

Predictive models for adverse clinical outcomes in Chinese patients with atrial fibrillation undergoing percutaneous coronary intervention with stenting

OBJECTIVE

This study aimed to evaluate predictors for adverse cardiovascular outcomes in patients with atrial fibrillation (AF) undergoing coronary stenting.

METHODS

We retrospectively recruited consecutive patients with previously documented non-valvular AF who underwent coronary stenting between January 2010 and June 2015 in 12 hospitals of Beijing, China. Major adverse cardiac/cerebrovascular events (MACCE) were a composite of all-cause death, non-fatal myocardial infarction, repeat revascularization, and ischaemic stroke/systemic thromboembolism (IS/STE). Major bleeding referred to grade 2 or higher of Bleeding Academic Research Consortium criteria.

RESULTS

A total of 2394 patients (men: 72.3% vs. women: 27.7%, median age: 67 years) were included. The CHA₂DS₂-VASc and HAS-BLED were 3.6 ± 1.6 and 1.9 ± 0.7, respectively. The median follow-up duration was 36.2 months. There were 230 (9.6%) deaths, 96 (4.0%) IS/STE, 426 (17.8%) MACCE, and 72 (3.0%) major bleeding. Multivariate Cox regression yielded predictive models for (1) all-cause death: diabetes, prior myocardial infarction, chronic kidney disease (CKD), ST-segment elevation myocardial infarction (STEMI) at presentation, heart failure, no use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins; (2) IS/STE: advanced age, prior history of ischaemic stroke and intracranial haemorrhage; (3) MACCE: prior history of myocardial infarction and ischaemic stroke, CKD, STEMI, heart failure, and no statin use; (4) major bleeding: prior major bleeding, prior myocardial infarction, CKD and use of oral anticoagulants.

CONCLUSION

Chinese patients with AF and coronary stenting had high mortality and incidence of MACCE. We compiled separate predictive models for all-cause death, IS/STE, MACCE, and major bleeding.

Adverse 30-Day Clinical Outcomes and Long-Term Mortality Among Patients With Preprocedural Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

OBJECTIVES

Approximately 5-10% of patients presenting for percutaneous coronary intervention (PCI) have concurrent atrial fibrillation (AF). To what extent AF portends adverse long-term outcomes in these patients remains to be defined.

METHODS

We analysed data from the multicentre Melbourne Interventional Group Registry from 2014-2018. Patients were identified as being in AF or sinus rhythm (SR) at the commencement of PCI. The primary endpoint was long-term mortality, obtained via linkage with the National Death Index.

RESULTS

13,286 procedures were included, with 800 (6.0%) patients in AF and 12,486 (94.0%) in SR. Compared to SR, patients with AF were older (72.9±10.9 vs 64.1±12.0 p<0.001) and more likely to have comorbidities including diabetes mellitus (31.3% vs 25.0% p<0.001), hypertension (74.4% vs 65.1% p<0.001) and moderate to severe left ventricular systolic dysfunction (36.6% vs 19.5% p<0.001). Atrial fibrillation was associated with an increased risk of in-hospital mortality (11.0% vs 2.5% p<0.001) and MACE (composite of all-cause mortality, myocardial infarction, or target vessel revascularisation) (11.9% vs 4.2% p<0.001). In-hospital major bleeding was more common in the AF group (3.1% vs 1.0% p<0.001). On Cox proportional hazards modelling, AF was an independent predictor of long-term mortality (adjusted HR 1.38 95% CI 1.11-1.72 p<0.004) at a mean follow-up of 2.3±1.5 years.

CONCLUSIONS

Preprocedural AF is common among patients presenting for PCI. Preprocedural AF is associated with high-rates of comorbid illnesses and portends higher risk of short- and long-term outcomes including mortality underscoring the need for careful evaluation of its risks prior to PCI.

Development and Validation of a Nomogram for Predicting Mortality in Patients with Atrial Fibrillation and Acute Coronary Syndrome Who Underwent Percutaneous Coronary Intervention in a Chinese Multicenter Cohort

Background

This study is aimed at to establish an effective prognostic nomogram for patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) underwent percutaneous coronary intervention (PCI).

Methods

The nomogram was based on a retrospective study of 977 patients with AF and ACS who underwent PCI who were admitted to any of the 11 tertiary hospitals in the Beijing area between 2009 and 2015. The predictive accuracy and discriminative ability of the nomogram were determined by a concordance index (C-index) and calibration curve and were compared using current risk scores such as GRACE, CRUSADE, CHA2DS2-VASc, and HAS-BLED. The results were validated using bootstrap resampling and a retrospective cohort study of 409 patients enrolled in Fuwai Hospital at the same institution.

Results

Independent factors derived from multivariable analysis of the primary cohort to predict all-cause mortality were age, pattern of ACS, red blood cell distribution width, N-terminal proBNP, and serum creatinine, all of which were assembled into the nomogram. The calibration curve for the probability of recurrence showed that the nomogram-based predictions were in good agreement with actual observations. The C-index of the nomogram for predicting mortality was 0.764 (95% CI, 0.718-0.810), which was statistically higher than the C-index values for the current risk scores (from 0.573 to 0.681). In the validation cohort, the C-index of the nomogram for predicting all-cause death was 0.706 (95% CI 0.601-0.811), with no significant differences compared with GRACE and CRUSADE, but better than that of CHA2DS2-VASc and HAS-BLED.

Conclusions

The nomogram has good prognostic prediction for patients with AF and ACS who underwent PCI.

Propafenone use in coronary artery disease patients undergoing atrial fibrillation ablation

BACKGROUND

Antiarrhythmic drugs (AADs) are frequently used after atrial fibrillation (AF) ablation. Class IC AAD use after AF ablation in patients with coronary artery disease (CAD) is uncertain. The aim was to evaluate propafenone use in CAD patients undergoing AF ablation and to compare propafenone with amiodarone regarding ventricular arrhythmia and mortality.

METHODS

In this retrospective, longitudinal cohort study, consecutive patients with mild to moderate CAD, undergoing AF ablation and receiving either propafenone (study group, n = 263) or amiodarone (control group, n = 499) in the blanking period, were included. After propensity score matching, 212 patients in each group were compared for the primary outcome defined as a composite of ventricular arrhythmic events, which included sudden cardiac death, sustained ventricular tachycardia or fibrillation, or non-sustained ventricular tachycardia (NSVT). Cardiovascular and non-cardiovascular mortality were evaluated as secondary outcomes.

RESULTS

Baseline variables of the study and control groups were well matched after propensity score matching. At 12-month follow up, 20 patients (4.7%) (11 in propafenone group and 9 in amiodarone group) experienced the primary outcome measure of NSVT (Gray test p = 0.645). No sustained ventricular tachycardia, ventricular fibrillation, sudden cardiac death, or cardiovascular mortality were observed. On multivariable competing analysis, age and diabetes but not propafenone use (hazard ratio 1.017; p = 0.804) were found to be independent and significant predictors of the primary outcome measure.

CONCLUSION

Propafenone use after AF ablation in patients with mild to moderate CAD had a safety profile similar to amiodarone and was not associated with major arrhythmic events.

Management of Acute Coronary Syndrome in Cancer Patients: It's High Time We Dealt with It

Cancer patients have an increased risk of cardiovascular disease and, notably, a significant prevalence of acute coronary syndrome (ACS). It has been shown that an elevated presence of cardiovascular risk factors in this setting leads to an interaction between these two conditions, influencing their therapeutic strategies and contributing to higher mortality. Nonetheless, cancer patients have generally not been evaluated in ACS trials, so that the treatment in these cases is still not fully known. We reviewed the current literature and discussed the best management for these very high-risk patients. The treatment strategy must be tailored based on the cancer type and stage, balancing thrombotic and bleeding risks. When the prognosis is longer than six months, especially if a clinical instability coexists, patients with ACS and cancer should be referred for percutaneous coronary intervention (PCI) as soon as possible. Moreover, an invasive strategy should be preferred in STEMI patients as well as in NSTEMI patients who are considered as high risk. On the contrary, in clinically stable NSTEMI patients, a conservative non-invasive strategy could be adopted, especially in cases of a poor life expectancy and/or of high risk of bleeding. Drug-Eluting-Stents (DES) should be the first choice if an invasive strategy is adopted. Conservative therapy could instead be considered in cancer patients with more stable CAD at an increased risk of major bleeding complications. However, the duration of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended, but it should be as short as possible, whereas triple antithrombotic therapy is non-advised because it significantly increases the risk of bleeding. ACS management among cancer patients should be based on an accurate evaluation of the risk of thrombosis and bleeding. Future studies focused on choosing optimal strategies in tumor patients with ACS should be performed to treat this subset of patients better.

Clinical Significance of Atrial Fibrillation Status in Patients With Percutaneous Coronary Intervention

Background

Patients undergoing percutaneous coronary intervention (PCI) often develop atrial fibrillation (AF). We investigated the clinical effects of AF status on in-hospital mortality and complications in patients with PCI using a recent large-scale nationwide dataset.

Methods

Using a claims-based dataset from 1022 hospitals in Japan for the time period between 2012 and 2016, patients with PCI were identified and classified into 3 groups according to AF status: no AF, prevalent AF before admission, and incident AF after admission. In-hospital mortality, complications, and medical costs were compared in crude and propensity-matched cohorts.

Results

In 659,525 hospitalized patients undergoing PCI, prevalent AF and incident AF were observed in 6.0% and 1.3% patients, respectively; the AF rates increased over 5 years. A greater proportion of older patients and patients with comorbidities had both of these categories of AF; undergoing PCI for acute coronary syndrome was common in incident AF. Both prevalent AF and incident AF were associated with worse crude outcomes and complications during hospitalization. In propensity-matched cohorts, incident AF was associated with a higher in-hospital mortality rate, longer length of stay, higher direct costs, and higher rate of complications, including stroke and acute kidney injury, compared with prevalent AF. These outcomes, except length of in-hospital stay, did not change for either AF status over 5 years.

Conclusions

Prevalent AF and incident AF in patients undergoing PCI were both associated with deteriorating crude outcomes and complications; in particular, incident AF was associated with worse adjusted outcomes and complications. Further efforts are needed to improve patient outcomes in an aging society in which the incidence of AF is increasing.

The Association Between Recurrence of Atrial Fibrillation and Revascularization in Patients With Coronary Artery Disease After Catheter Ablation

Aim: The connection between revascularization for coronary artery disease (CAD) and the incidence of recurrent events of atrial fibrillation (AF) after ablation is unclear. This study aimed to explore the relationship between coronary revascularization and AF recurrence in patients who underwent radiofrequency catheter ablation (RFCA). Methods: Four hundred and nineteen patients who underwent performed coronary angiography at the same time as RFCA were enrolled in this study. Obstructive CAD was defined as at least one coronary artery vessel stenosis of ≥75% and percutaneous coronary intervention (PCI) was recommended. Non-obstructive CAD was defined as coronary artery vessel stenosis of <75%. The endpoint was freedom from recurrence from AF after RFCA during the 24-month follow-up. Results: In total, 102, 95, and 212 patients were undergone coronary angiography and diagnosed as having obstructive CAD, Non-obstructive CAD, and Non-CAD, respectively. During the 24-month follow-up period, patients without obstructive CAD were significantly more likely to achieve freedom from AF than patients with obstructive CAD (hazard ratio [HR]: 1.72; 95% confidence interval [CI]: 1.23-2.41; P = 0.001). The recurrence rate of AF was significantly lower in patients who underwent PCI than in those who did not (HR: 0.45; 95% CI: 0.25-0.80; P = 0.007). The multivariate regression analysis showed that the other predictors of AF recurrence for obstructive CAD were multivessel stenosis (HR: 1.92; 95% CI: 1.04-3.54; P = 0.036) and left atrial diameter (HR: 2.56; 95% CI: 1.31-5.00; P = 0.006). Conclusions: This study suggests that obstructive CAD is associated with a higher rate of AF recurrence. Additionally, For patients with CAD, coronary revascularization is related to a lower recurrence rate of AF after RFCA.

The role of triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention

Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel forms the backbone of secondary prevention in patients with acute coronary syndromes (ACS) or who undergo percutaneous coronary intervention (PCI), but in patients with atrial fibrillation (AF), oral anticoagulation (OAC) is superior to antiplatelet therapy for the prevention of stroke and systemic embolism. Patients with AF who undergo PCI or have an ACS event therefore have an indication for both OAC and DAPT, so-called triple antithrombotic therapy. However, observational analyses have shown that the annual rate of major bleeding on triple therapy exceeds 10%. For this reason, five major randomized clinical trials have compared double antithrombotic therapy with OAC and a P2Y₁₂ inhibitor versus triple therapy in patients with AF who underwent PCI or had an ACS event. Each of the trials showed that double antithrombotic therapy reduced the rate of major and clinically relevant non-major bleeding compared with triple therapy and was non-inferior for prevention of ischemic events, including cardiovascular death, myocardial infarction, or stroke. In the one trial that directly compared warfarin with a non-vitamin K antagonist oral anticoagulant (NOAC), apixaban reduced the rate of major or clinically relevant non-major bleeding compared with warfarin and was non-inferior with respect to prevention of ischemic events. As a result of these trials, consensus guidelines recommend that patients with AF who undergo PCI or have an ACS event should be treated with triple antithrombotic therapy (OAC + P2Y₁₂ inhibitor + aspirin) for 7 days or less, followed by double antithrombotic therapy (OAC + P2Y₁₂ inhibitor) for 6 to 12 months.

Cost-effectiveness analysis of apixaban versus vitamin K antagonists for antithrombotic therapy in patients with atrial fibrillation after acute coronary syndrome or percutaneous coronary intervention in Spain

BACKGROUND/OBJECTIVE

AUGUSTUS trial demonstrated that, for patients with atrial fibrillation (AF) having acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI), an antithrombotic regimen with apixaban and P2Y12 resulted in less bleeding, fewer hospitalizations, and similar ischemic events than regimens including a vitamin K antagonist (VKA), aspirin, or both. This study objective was to evaluate long-term health and economic outcomes and the cost-effectiveness of apixaban over VKA, as a treatment option for patients with AF having ACS/PCI.

METHODS

A lifetime Markov cohort model was developed comparing apixaban versus VKA across multiple treatment strategies (triple [with P2Y12 + aspirin] or dual [with P2Y12] therapy followed by monotherapy [apixaban or VKA]; triple followed by dual and then monotherapy; dual followed by monotherapy). The model adopted the Spanish healthcare perspective, with a 3-month cycle length and costs and health outcomes discounted at 3%.

RESULTS

Treatment with apixaban resulted in total cost savings of €883 and higher life years (LYs) and quality-adjusted LYs (QALYs) per patient than VKA (net difference, LYs: 0.13; QALYs: 0.11). Bleeding and ischemic events (per 100 patients) were lower with apixaban than VKA (net difference, -13.9 and -1.8, respectively). Incremental net monetary benefit for apixaban was €3,041, using a willingness-to-pay threshold of €20,000 per QALY. In probabilistic sensitivity analysis, apixaban was dominant in the majority of simulations (92.6%), providing additional QALYs at lower costs than VKA.

CONCLUSIONS

Apixaban was a dominant treatment strategy than VKA from both the Spanish payer's and societal perspectives, regardless of treatment strategy considered.

Prediction of all-cause mortality in coronary artery disease patients with atrial fibrillation based on machine learning models

BACKGROUND

Machine learning (ML) can include more diverse and more complex variables to construct models. This study aimed to develop models based on ML methods to predict the all-cause mortality in coronary artery disease (CAD) patients with atrial fibrillation (AF).

METHODS

A total of 2037 CAD patients with AF were included in this study. Three ML methods were used, including the regularization logistic regression, random forest, and support vector machines. The fivefold cross-validation was used to evaluate model performance. The performance was quantified by calculating the area under the curve (AUC) with 95% confidence intervals (CI), sensitivity, specificity, and accuracy.

RESULTS

After univariate analysis, 24 variables with statistical differences were included into the models. The AUC of regularization logistic regression model, random forest model, and support vector machines model was 0.732 (95% CI 0.649-0.816), 0.728 (95% CI 0.642-0.813), and 0.712 (95% CI 0.630-0.794), respectively. The regularization logistic regression model presented the highest AUC value (0.732 vs 0.728 vs 0.712), specificity (0.699 vs 0.663 vs 0.668), and accuracy (0.936 vs 0.935 vs 0.935) among the three models. However, no statistical differences were observed in the receiver operating characteristic (ROC) curve of the three models (all P > 0.05).

CONCLUSION

Combining the performance of all aspects of the models, the regularization logistic regression model was recommended to be used in clinical practice.

Antiplatelet Effect of Single Antiplatelet Therapy With Prasugrel and Oral Anticoagulation After Stent Implantation in a Rabbit Arteriovenous Shunt Model

Background: Antiplatelet therapy following stent implantation in patients requiring oral anticoagulation (OAC) is controversial because triple therapy (i.e., dual antiplatelet therapy [DAPT] with OAC) is associated with a high risk of bleeding. Methods and Results: In this study, 21 rabbits were divided into 5 groups: prasugrel and warfarin (Prasugrel+OAC group); aspirin and warfarin (Aspirin+OAC group); prasugrel, aspirin, and warfarin group (Triple group); prasugrel and aspirin (Conventional DAPT group); and no medication (Control group). The treated groups were administered medication for 1 week. An arteriovenous shunt loop was established from the rabbit carotid artery to the jugular vein and 2 bare metal stents were deployed in a silicone tube. After 1 h of circulation, the volume of thrombi was evaluated quantitatively by measuring the amount of protein. Bleeding time was measured at the same time. The volume of the thrombus (amount of protein) around stent struts was lowest in the Triple group, followed by the Prasugrel+OAC and Conventional DAPT groups, and was highest in the Control group. Bleeding time was the longest in the Triple group, followed by the Aspirin+OAC, Prasugrel+OAC, Conventional DAPT, and Control groups. Conclusions: This study suggests that prasugrel with OAC may be a feasible antithrombotic regimen following stent implantation in patients who require OAC therapy.

Long term risk and costs of bleeding in men and women treated with triple antithrombotic therapy-An observational study

OBJECTIVES

Bleeding is the most common non-ischemic complication in patients with coronary revascularisation procedures, associated with prolonged hospitalisation and increased mortality. Many factors predispose for bleeds in these patients, among those sex. Anyhow, few studies have characterised the population receiving triple antithrombotic therapy (TAT) as well as long term bleeds from a sex perspective. We investigated the one year rate of bleeds in patients receiving TAT, potential sex disparities and premature discontinuation of TAT. We also assessed health care costs in bleeders vs non-bleeders.

SETTING

Three hospitals in the County of Östergötland, Sweden during 2009-2015.

PARTICIPANTS

All patients discharged with TAT registered in the SWEDEHEART registry.

PRIMARY AND SECONDARY OUTCOME MEASURES

All bleeds receiving medical attention during one-year follow-up were collected by retrieving relevant information about each patient from medical records. Resource use associated with bleeds was assigned unit cost to estimate the health care costs associated with bleeding episodes.

RESULTS

Among 272 patients, 156 bleeds occurred post-discharge, of which 28.8% were gastrointestinal. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p = 0.01) and bled more (48.6 vs. 37.1%, p = 0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively.

CONCLUSION

The high bleeding incidence in patients with TAT, especially in women, is a cause of concern. There is a need for an adequately sized randomised, controlled trial to determine a safe but still effective treatment for these patients.

Mechanical Circulatory Support in High-Risk Percutaneous Coronary Intervention

The use of mechanical circulatory devices to support high-risk elective percutaneous coronary intervention (PCI) has become more common as the group of patients considered inoperable or high risk for surgical revascularization has grown. Most of the data examining outcomes in high-risk PCI are observational and retrospective. Limited prospective randomized studies have been unable to show improved clinical outcomes with routine mechanical circulatory support (MCS) in patients with a high burden of coronary artery disease and reduced ejection fraction. The role for MCS in high-risk PCI continues to evolve as understanding of the appropriate groups for this therapy evolves.

Comparative Safety of Bioabsorbable Polymer Everolimus-Eluting, Durable Polymer Everolimus-Eluting, and Durable Polymer Zotarolimus-Eluting Stents in Contemporary Clinical Practice

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A predictive nomogram of bleeding risk in patients with atrial fibrillation after drug-eluting stent implantation

BACKGROUND

The use of anticoagulants and antiplatelet therapies is associated with a higher risk of bleeding in atrial fibrillation (AF) patients after percutaneous coronary intervention, especially after stent implantation. However, no accurate bleeding risk prediction tool has been developed for these patients. The aim of this study was thus to establish a bleeding risk prediction model (predictive nomogram) for patients with AF after stent implantation.

METHODS

Construction of the predictive nomogram was based on a retrospective study, which enrolled 943 AF patients who underwent drug-eluting stent implantation between May 2012 and September 2016. A range of factors, including demographics, comorbidities, medication strategies, arterial access, and laboratory tests, were collected as baseline data. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analysis were used to identify the key clinical features for construction of the predictive nomogram. The concordance index (C-index) and internal validation were used to evaluate the efficacy of the nomogram.

RESULTS

Of the 943 AF patients that underwent stent implantation, the occurrence of bleeding events was 8.2% (77 out of 943). Key predictors included the number of antiplatelet drugs, peptic ulcer, cerebral infarction, type 2 diabetes, thrombocytopenia, anemia, prior myocardial infarction, sex (male), use of anticoagulant drugs, liver dysfunction, hypertension, and acute myocardial infarction. These predictors were used to construct the nomogram. The C-index for the prediction of bleeding risk by the nomogram was 0.841 (95% CI: 0.79-0.89), which indicated good discrimination and calibration. The C-index of internal validation was 0.795, which demonstrated good efficacy of the model.

CONCLUSIONS

This study suggests that our novel nomogram can accurately predict bleeding risk in AF patients after stent implantation during hospitalization, thereby helping to avoid complications. The nomogram may also be helpful for the creation of individualized post-discharge medication strategies.

Comparison of clinical outcomes between multiple antithrombotic therapy versus left atrial appendage occlusion with dual antiplatelet therapy in patients with atrial fibrillation undergoing drug-eluting stent implantation

Background

Complex antithrombotic regimens are recommended for patients with atrial fibrillation (AF) undergoing drug-eluting stent (DES) implantation but carry high bleeding risk.

Hypothesis

We aimed to evaluate whether left atrial appendage occlusion (LAAO) with dual antiplatelet therapy (DAPT) improve clinical outcomes when compared with multiple antithrombotic therapy (MAT) in patients with AF undergoing DES implantation.

Methods

Among 475 AF patients who underwent DES, 41 patients treated by LAAO with DAPT and 434 patients on MAT were compared. MAT was defined as any combination of warfarin-based antithrombotic therapy. Among the MAT group, 34.8% were on triple antithrombotic therapy. The primary endpoint was a net adverse clinical event (NACE), a composite of cerebrovascular accident (CVA) and major bleeding. Secondary endpoints were CVA, major bleeding, major adverse cardiac and cerebral event (MACCE), MI, cardiovascular death, and all-cause death. Additional analysis between the new oral anticoagulant (NOAC)-based antithrombotic therapy group (n = 45) and the LAAO group was performed for the same endpoints. To adjust the confounding factors, inverse probability of treatment weighting (IPTW) was applied during the endpoint analysis.

Results

The LAAO group showed higher incidences of diabetes mellitus, prior CVA, higher CHA2DS2-VASc score (4.56±1.55 vs. 2.96±1.60; P<0.0001), and higher HAS-BLED score (3.24±1.20 vs. 2.13±0.75; P<0.0001). NACE occurred less frequently in the LAAO group than the MAT group at 24 months (9.4% vs. 15.3%; hazard ratio 0.274; 95% confidence interval 0.136 – 0.553; P = 0.0003), mainly driven by the reduction in major bleeding (2.4% vs. 9.3%; hazard ratio 0.119; 95% confidence interval 0.032 – 0.438; P = 0.001). The LAAO group with greater thrombotic and hemorrhagic risks showed comparable primary/secondary outcomes with the NOAC-based anti-thrombotic therapy group.

Conclusions

Among patients with AF who underwent DES implantation, the LAAO group had better net clinical outcomes for preventing CVA and major bleeding than the MAT group. Further large-scale trials including comparisons with NOACs are warranted.

In-Hospital Bleeding Outcomes of Myocardial Infarction in the Era of Warfarin and Direct Oral Anticoagulants for Atrial Fibrillation in the United States: A Report From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry

Background

We sought to examine patient characteristics, peri‐infarction invasive and pharmacologic management, and in‐hospital major bleeding in myocardial infarction patients with atrial fibrillation or flutter, based on home anticoagulant use.

Methods and Results

We stratified patients by home anticoagulant: (1) no anticoagulant, (2) warfarin, and (3) direct oral anticoagulants (DOACs) among ST‐segment–elevation myocardial infarction (STEMI) and non‐STEMI (NSTEMI) patients with atrial fibrillation or flutter treated at 761 US hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. The primary outcome of our study was in‐hospital major bleeding. Multivariable logistic regression was used to examine the independent association between home anticoagulant and in‐hospital major bleeding. Among 6471 STEMI patients with atrial fibrillation or flutter, 15.7% were on warfarin and 13.0% on DOACs; among 19 954 NSTEMI patients, 22.8% were on warfarin and 15.4% on DOACs. In STEMI, door‐to‐balloon times were slightly higher in those on anticoagulant, with similar rates of angiography within 24 hours in the 3 groups. NSTEMI patients on anticoagulant were less likely to undergo angiography (49.3% no anticoagulant, 33.4% on warfarin, 36.4% on DOACs; P<0.01) or percutaneous coronary intervention within 24 hours (21.1% no anticoagulant, 14.3% on warfarin, 15.9% on DOACs; P<0.01). After multivariate adjustment, use of home warfarin (odds ratio: 1.00 [95% CI, 0.79–1.27] in STEMI and 1.13 [95% CI, 0.97–1.30] in NSTEMI) or DOAC (odds ratio: 0.93 [95% CI, 0.73–1.20] in STEMI and 0.97 [95% CI, 0.81–1.16] in NSTEMI) was not associated with increased in‐hospital major bleeding compared with no anticoagulant.

Conclusions

In routine clinical practice, home warfarin or DOAC therapy is not associated with an increased risk of in‐hospital bleeding compared with no anticoagulant.

Applying the CHA2DS2-VASc score to predict the risk of future acute coronary syndrome in patients receiving catheter ablation for atrial fibrillation

•

AF patients without catheter ablation have a higher risk of future ACS when compared to normal control group.

•

The presence of AF without catheter ablation is an independent risk factor for future acute coronary events.

•

Catheter ablation to AF could reduce future risk of acute coronary events over a very long-term follow-up.

•

The cut-off value of baseline CHA₂DS₂-VASc score ≥ 4 can strongly predict future acute coronary events in patients with AF.

Objective

It remains unknown whether catheter ablation for atrial fibrillation (AF) reduces future acute coronary syndrome (ACS) risk or whether the CHA₂DS₂-VASc score has a role in predicting this risk. We aimed to compare very long-term risk of ACS between patients who received catheter ablation to AF or antiarrhythmic medications and controls without AF.

Methods

Propensity scores were calculated for each patient and used to assemble a cohort of 787 patients undergoing AF ablation in 2003–2012. Patients were compared to an equal number of AF patients treated with antiarrhythmic medications and a control group without AF. Patients with previous coronary events were excluded. The primary endpoint was ACS occurrence.

Results

Baseline clinical characteristics were comparable. After a mean 9.1 ± 3.2-year follow-up, the ablation group had lower incidence of new onset ACS than the medication and non-AF control groups (annual incidence: 0.15%. 0.78%, and 0.35%; with 2.67, 4.16, and 10.44 cases/1000 person-years, respectively; P < 0.001). After adjusting for multiple confounders, the ablation group had lower future ACS risk than the medication (hazard ratio [HR]: 0.20, 95% confidence interval [CI]: 0.13–0.30) and control groups (HR: 0.30, 95% CI: 0.20–0.45). The CHA₂DS₂-VASc score was a strong predictor of ACS (HR: 1.61, 95% CI: 1.47–1.76; AUC: 85.9%, 95% CI: 78.5–93.2%). A baseline CHA₂DS₂-VASc score ≥ 4 predicted future ACS (positive predictive rate: 14.3%).

Conclusions

This study suggested that catheter ablation for AF may be beneficial to reduce future ACS risk in AF patients, and a high baseline CHA₂DS₂-VASc score can predict future acute coronary events.

The Impact of Atrial Fibrillation on In-Hospital Outcomes in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock Undergoing Coronary Revascularization with Percutaneous Ventricular Assist Device Support

Background

Atrial fibrillation (AF) is common in acute myocardial infarction complicated by cardiogenic shock (AMI-CS) requiring percutaneous ventricular assist device (pVAD-Impella®) support during percutaneous coronary interventions (PCI). We evaluated the effects of a coexistent diagnosis of AF on clinical outcomes in patients with AMI-CS undergoing PCI with pVAD support.

Methods

The National Inpatient Sample (2008-2014) was queried to identify patients with AMICS requiring PCI with pVAD support and had a concomitant diagnosis of AF. Propensity-matched cohorts (AF+ vs AF-) were compared for in-hospital outcomes.

Results

A total of 840 patients with AMICS requiring PCI with pVAD support (420 AF+ vs 420 AF-) were identified in the matched cohort. Patients with AF were older (mean 69.7±12.0 vs 67.9±11.3 yrs, p=0.030). All-cause in-hospital mortality rates between the two groups were similar (40.5% vs 36.7%, p=0.245); however, higher postprocedural respiratory complications (9.5% vs 4.8%, p=0.007) were seen in AF+ group. In-hospital cardiac arrests were more frequent in the AF- group (32.0% vs 19.2%, p<0.001). We examined the length of stay (LOS), transfer to other facilities, and hospital charges as metrics of health care resource consumption and found that the AF+ cohort experienced fewer routine discharges (13.1% vs 30.2%), more frequent transfers to other facilities including skilled nursing facilities or intermediate care facilities (27.3% vs 17.8%; p<0.001), more frequently required the use of home health care (14.3% vs 7.1%; p<0.001). The mean LOS (11.9±10.1 vs 9.11±6.8, p<0.001) and hospital charges ($308,478 vs $277,982, p=0.008) were higher in the AF+ group.

Conclusions

In patients suffering AMICS requiring PCI and pVAD support, a coexistent diagnosis of AF was not associated with an increase in all-cause in-hospital mortality as compared to patients without AF. However, healthcare resource consumption as assessed by various metrics was consistently greater in the AF+ group.

Practical guidance for P2Y12 inhibitors in acute myocardial infarction undergoing percutaneous coronary intervention

AIMS

Potent P2Y12 inhibitors for dual antiplatelet therapy (DAPT) is crucial for managing acute myocardial infarction; however, the selection of drugs is based on limited clinical information such as age and body weight. The current study sought to develop and validate a new risk scoring system that can be used to guide the selection of potent P2Y12 inhibitors by balancing ischaemic benefit and bleeding risk.

METHODS AND RESULTS

Derivation cohort of 10 687 patients who participated in the Korea Acute Myocardial Infarction Registry-National Institutes of Health study was used to construct a new scoring system. We combined the ischaemic and bleeding models to establish a simple clinical prediction score. Among the low score group (n = 1764), the observed bleeding risk (8.7% vs. 4.4%, P < 0.001) due to potent P2Y12 inhibitors exceeded ischaemic benefit (1.3% vs. 2.2%, P = 0.185) during 12 months. Conversely, the high score group (n = 1898) showed an overall benefit from taking potent P2Y12 inhibitors from the standpoint of observed ischaemic (17.1% vs. 8.6%, P < 0.001) and bleeding events (10.1% vs. 6.8%, P = 0.073). The performance of ischaemic [integrated area under the curve (iAUC) = 0.809] and bleeding model (iAUC = 0.655) was deemed to be acceptable.

CONCLUSION

The new scoring system is a useful clinical tool for guiding DAPT by balancing ischaemic benefit and bleeding risk, especially among Asian populations. Further validation studies with other cohorts will be required to verify that the new system meets the needs of real clinical practice.

Temporal trends in prevalence and outcomes of atrial fibrillation in patients undergoing percutaneous coronary intervention

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia in patients undergoing percutaneous coronary intervention (PCI).

HYPOTHESIS

Large administrative data may provide further insight into temporal trends in the prevalence and burden of AF in patients who underwent PCI.

METHODS

Using the National Inpatient Sample database in the U.S., AF patients ≥18 years who underwent PCI between 2005 and 2014 and were identified by the International Classification of Diseases, ninth revision, Clinical Modification, were examined. In-hospital mortality, morbidity, resource use, and medical costs were evaluated in crude and propensity-matched analyses.

RESULTS

Among an estimated 6 272 232 hospitalizations, of patients undergoing PCI, AF prevalence was 9.9% and steadily increased from 8.6% to 12.0% between 2005 and 2014 (P < .001); there was also a greater proportion of comorbidities. There was a marked increase in AF prevalence among those aged ≥65 years and those undergoing elective PCIs. AF was independently associated with higher in-hospital mortality and higher rates of transient ischaemic attack/stroke, bleeding complications, and non-home discharge. Excessive in-hospital mortality, stroke rate, gastrointestinal bleeding, blood transfusion, length of stay, and costs among AF hospitalizations were consistently observed throughout the study period.

CONCLUSION

AF becomes more prevalent in patients undergoing PCI, possibly due to a higher comorbidity, particularly in elderly patients with non-acute indications. Less favorable trends in mortality, bleeding, and stroke among AF patients who underwent PCI were consistent over time. Continuous efforts are needed to improve outcomes and manage strategies for AF patients undergoing PCI.

Sex difference in clinical outcomes of Chinese patients with atrial fibrillation and coronary stenting according to age

OBJECTIVE

Sex differences in the clinical outcomes of patients with atrial fibrillation (AF) and coronary stenting should be assessed according to age.

METHODS

We analyzed the clinical data of all patients with nonvalvular AF who underwent coronary stenting between January 2010 and June 2015 in 12 hospitals of Beijing, China.

RESULTS

A total of 2,146 patients (71.8% men and 28.2% women) were included in the study. The mean age of the patients was 66.6±9.4 years. Women in this study were older and had higher prevalence of hypertension, diabetes, chronic kidney disease (CKD), and anemia. Smoking history was found to be higher in men, and women were less likely to be current smokers. The mean follow-up duration was 39.7 months. Women younger than 65 years had a remarkably higher mortality (11.2% vs. 5.3%, p=0.012) and a significantly lower rate of repeat revascularization (1.6% vs. 6.3%, p=0.034) than men. Female gender remained an independent predictor for all-cause mortality [hazard ratio (HR)=2.03, 95% confidence interval (CI): 1.09-3.79, p=0.025], along with heart failure (HR=3.64, 95% CI: 2.02-6.57, p<0.001) and CKD (HR=2.46, 95% CI: 1.09-5.57, p=0.031) after multivariate regression analysis. No significant difference was noted between men and women with regard to mortality, ischemic events, and major bleeding in elderly patients.

CONCLUSION

In Chinese patients younger than 65 years with AF and coronary stenting, female gender was independently associated with increased mortality; men were more likely to receive repeat revascularization possibly due to the current smoking. Whether it was a biological difference or a recognition disparity of the disease between men and women warrants further investigation.

Association of Timing of Aortic Valve Replacement Surgery After Stroke With Risk of Recurrent Stroke and Mortality

Importance

Timing of surgical aortic valve replacement (SAVR) in patients with aortic valve stenosis and previous stroke for the risk of recurrent stroke is insufficiently investigated.

Objective

To evaluate the association of time elapsed between previous stroke and SAVR with the risk of recurrent perioperative stroke, major adverse cardiovascular events (MACE), and mortality among patients with aortic valve stenosis.

Design, Setting, and Participants

This cohort study using data from Danish administrative registries included all patients with aortic valve stenosis older than 18 years who underwent SAVR between 1996 and 2014 (n = 14 030). Patients who received simultaneous mitral, tricuspid, or pulmonary valve surgery and patients with endocarditis 1 year prior to surgery were excluded. Data were analyzed from March 2017 to January 2018.

Exposures

Time elapsed between prior stroke and SAVR (<3 months, 3-<12 months, ≥12 months, and no prior stroke).

Main Outcomes and Measures

Thirty-day risks of MACE, ischemic stroke, and all-cause mortality reported as absolute events and multivariable adjusted odds ratios with 95% confidence intervals. Restricted cubic spline regression models were additionally applied on the subgroup with prior stroke.

Results

Of the 14 030 included patients, 616 patients (190 [30.8%] women; mean [SD] age, 72.0 [9.1] years) with prior stroke underwent surgery, and 13 414 (4837 [36.1%] women; mean [SD] age, 69.8 [10.8] years) without prior stroke underwent surgery. The absolute risk of ischemic stroke was significantly increased in patients with stroke less than 3 months prior to surgery compared with patients with no prior stroke (18.4% [37 of 201] vs 1.2% [160 of 13 219]; odds ratio, 14.69; 95% CI, 9.69-22.27). Likewise, compared with patients without stroke, patients with stroke less than 3 months prior surgery were at significantly increased risk of MACE (23.3% [53 of 227] vs 5.7% [768 of 13 414]; odds ratio, 4.57; 95% CI, 3.24-6.44) but not all-cause mortality (6.8% [50 of 730] vs 3.6% [374 of 10 370]; odds ratio, 1.45; 95% CI, 0.83-2.54). Spline analyses supported a declining risk over time, reaching nadir after 2 to 4 months.

Conclusions and Relevance

Previous stroke is a major risk factor of recurrent ischemic stroke and MACE in patients undergoing SAVR, especially if time elapsed between previous stroke and surgery is less than 3 months.

Risk of new-onset atrial fibrillation after drug-eluting stent implantation in patients with stable coronary artery disease

BACKGROUND

New-onset atrial fibrillation (NOAF) is associated with adverse outcomes in patients with coronary artery disease (CAD). Although newer generation drug-eluting stents (NG-DESs) are more beneficial than bare-metal stents (BMSs) in reducing the risk of in-stent restenosis and revascularization, whether NG-DES implantation in patients with stable CAD reduces NOAF risk compared with BMS implantation remains unknown.

METHODS

This population-based cohort study was conducted using data from Taiwan's National Health Insurance Research Database. Propensity score matching was used to select 18,423 pairs of patients with stable CAD receiving NG-DES implantation and BMS implantation with similar baseline characteristics for evaluation. A competing risk model was used to evaluate the risk of NOAF between the NG-DES and BMS groups in which death was considered a competing risk.

RESULTS

After adjustment for patients' clinical variables, the use of NG-DESs was associated with a decreased risk of NOAF at 1-year follow-up (adjusted subdistribution hazard ratio [SHR] = 0.79, 95% confidence interval [CI] = 0.68-0.93, P = 0.005) compared with the use of BMSs. Similar results indicated that NG-DESs were beneficial for reducing the risk of NOAF (adjusted SHR = 0.81, 95% CI = 0.67-0.97, P = 0.020) in patients with a CHA₂DS₂-VASc score of ≥2. These findings were also consistent with those for patients who received dual antiplatelet therapy for an undefined duration of >1 month following stent implantation.

CONCLUSIONS

Our findings suggest that NG-DESs might reduce the risk of NOAF in patients with stable CAD.

Exploring the Healthcare Value of Percutaneous Coronary Intervention: Appropriateness, Outcomes, and Costs in Michigan Hospitals

BACKGROUND

Assessments of healthcare value have largely focused on measuring outcomes of care at a given level of cost with less attention paid to appropriateness. However, understanding how appropriateness relates to outcomes and costs is essential to determining healthcare value.

METHODS AND RESULTS

In a retrospective cohort study design, administrative data from fee-for-service Medicare patients undergoing percutaneous coronary intervention (PCI) in Michigan hospitals between June 30, 2010, and December 31, 2014, were linked with clinical data from a statewide PCI registry to calculate hospital-level measures of (1) appropriate use criteria scores, (2) 90-day risk-standardized readmission and mortality rates, and (3) 90-day risk-standardized episode costs. We then used Spearman correlation coefficients to assess the relationship between these measures. A total of 29 839 PCIs were performed at 33 PCI hospitals during the study period. A total of 13.3% were for ST-segment-elevation myocardial infarction, 25.0% for non-ST-segment-elevation myocardial infarction, 47.1% for unstable angina, 9.8% for stable angina, and 4.7% for other. The overall hospital-level mean appropriate use criteria score was 8.4±0.2. Ninety-day risk-standardized readmission occurred in 23.7%±3.7% of cases, 90-day risk-standardized mortality in 4.3%±0.6%, and mean risk-standardized episode costs were $26 159±$1074. Hospital-level appropriate use criteria scores did not correlate with 90-day readmission, mortality, or episode costs.

CONCLUSIONS

Among Medicare patients undergoing PCI in Michigan, we found hospital-level appropriate use criteria scores did not correlate with 90-day readmission, mortality, or episode costs. This finding suggests that a comprehensive understanding of healthcare value requires multidimensional consideration of appropriateness, outcomes, and costs.

Vitamin K antagonist vs direct oral anticoagulants with antiplatelet therapy in dual or triple therapy after percutaneous coronary intervention or acute coronary syndrome in atrial fibrillation: Meta-analysis of randomized controlled trials

BACKGROUND

The combination of vitamin K antagonists (VKA) for atrial fibrillation (AF) and antiplatelet agents following percutaneous coronary intervention (PCI) is associated with an increased bleeding risk.

HYPOTHESIS

Direct oral anticoagulants (DOAC) are associated with a greater safety profile but the optimal antithrombotic treatment strategy, especially when considering ischemic events, is unclear.

METHODS

We performed a meta-analysis of randomized controlled trials comparing outcomes in AF patients following PCI and/or acute coronary syndrome (ACS) when treated with DOAC vs VKA, both in combination with one (dual) or two (triple) antiplatelet regimens. A systematic review was performed by searches of electronic databases MEDLINE (source PubMed) and the Cochrane Controlled Clinical Trials Register Database as well as Cardiology annual meetings. Three studies were finally included.

RESULTS

Compared to VKA triple therapy, the use of DOAC was associated with a decreased risk of any bleeding (relative risk [RR] 0.68 [0.62; 0.74]), major bleeding (RR 0.61 [0.51; 0.75]) and intracranial bleeding (RR 0.33 [0.17; 0.66]) and similar rates of the composite efficacy endpoint (RR 1.0 [0.87; 1.14]) and its components. Similar and consistent results were observed with both dual and triple therapy including a DOAC compared to VKA.

CONCLUSION

Our meta-analysis supports the use of dual therapy combining a DOAC and clopidogrel as the default regimen in most AF patients after PCI and/or ACS.

Changes in renal function and occurrence of contrast-induced nephropathy after percutaneous coronary interventions in patients with atrial fibrillation treated with non-vitamin K oral anticoagulants or warfarin

INTRODUCTION

Patients with atrial fibrillation (AF) receiving non-vitamin K oral anticoagulants (NOAC) have a slower decline in renal function than those taking warfarin. Moreover, a warfarin-related nephropathy has been described.

AIM

We assessed variation of estimated glomerular filtration rate (eGFR) and occurrence of contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) in patients with AF taking warfarin compared with NOAC.

MATERIAL AND METHODS

We retrospectively enrolled consecutive patients taking oral anticoagulation for AF undergoing PCI. The primary endpoint was variation in eGFR and serum creatinine levels within 48-72 h after PCI. The secondary endpoint was occurrence of CIN, defined as a ≥ 25% relative increase, or a ≥ 0.5 mg/dl absolute increase, in serum creatinine levels within 48-72 h.

RESULTS

We enrolled 420 patients (mean age: 75.0 ±5.5 years, 272 (64.7%) male), 124 (29.5%) treated with NOAC and 296 (70.5%) with warfarin. NOAC patients showed a reduced decline in renal function (eGFR change: -2.8 ±7.9 ml/min/1.73 m2 vs. -4.5 ±6.5 ml/min/1.73 m2, respectively, p = 0.02) and a smaller increase in serum creatinine levels (0.026 ±0.112 vs. 0.055 ±0.132, p = 0.032) after PCI compared with warfarin. In the multivariate linear regression model independent predictors of eGFR changes were diabetes, baseline eGFR ≤ 60 ml/min/1.73 m2 and warfarin use. Occurrence of CIN did not differ between NOAC and warfarin patients (13 (10.5%) vs. 46 (15.5%), p = 0.22).

CONCLUSIONS

Patients with AF taking NOAC have a reduced decline in renal function after PCI compared with warfarin. The NOAC may be a reasonable option for patients with a high risk of developing CIN.

Role of cardiovascular implantable electronic devices in delivering individualized disease-guided management of patients with non-valvular atrial fibrillation and high bleeding risk

BACKGROUND

Many patients with non-valvular atrial fibrillation (NVAF) with high risk for thromboembolic stroke and bleeding may not wish to continue long-term oral anticoagulants (OACs) to avoid bleeding complications. We aimed to investigate whether AF burden assessment by cardiovascular implantable electronic devices (CIEDs) would allow an individualised disease-guided approach for safe withdrawal of long-term OAC in high-risk patients.

METHODS AND RESULTS

We studied 145 patients (age 77.6 ± 10.6 years; 49.7% females) with NVAF, CHA₂DS₂-VASc score ≥2, HAS-BLED score ≥3, in whom CIEDs were implanted. These patients wished to stay off long-term OAC based on their previous adverse bleeding event/s or due to similar events witnessed in the family or friend circle. These patients were grouped into 'low AF burden' [n = 121 (83%)], or 'high AF burden' [n = 24 (17%)] defined as <24 hours or >24 hours cumulatively in 30 consecutive days respectively, and followed for 51.2 ± 29.8 months. All patients with 'low AF burden' were allowed to discontinue OAC, but OAC was resumed in 1 patient who experienced TIA. Bleeding events developed in 9 out of 24 (37.5%) patients with 'high AF burden' who were maintained on OAC, as compared to 3 out of 121 (2.47%) patients with 'low AF burden' who were off OAC (p <.05). There were 9 (6.2%) deaths unrelated to AF treatment approach.

CONCLUSIONS

In NVAF patients, AF burden assessment by CIEDs allows an individualised disease-guided approach to safe withdrawal of long-term OAC in patients with high bleeding risk who do not wish to continue long-term anticoagulation.

Temporal trends in prevalence and antithrombotic treatment among Asians with atrial fibrillation undergoing percutaneous coronary intervention: A nationwide Korean population-based study

Background

We investigated the recent 10-year trends in the number of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) in relation to prescription patterns of antithrombotic therapy.

Methods

We analyzed the annual prevalence of PCI and patterns of antithrombotic therapy after PCI, including antiplatelets and oral anticoagulants (vitamin K antagonists and non-vitamin K antagonist oral anticoagulants [NOACs]), in patients with AF between 2006 and 2015 by using the Korean National Health Insurance Service database. Independent factors associated with triple therapy (oral anticoagulant plus dual antiplatelet) prescription were assessed using multivariable logistic regression analysis.

Results

The number of patients with AF undergoing PCI increased gradually from 2006 (n = 2,140) to 2015 (n = 3,631) (p_trend<0.001). In 2006, only 22.7% of patients received triple therapy after PCI although 96.2% of them were indicated for anticoagulation (CHA₂DS₂-VASc score ≥2). The prescription rate of triple therapy increased to 38.3% in 2015 (p_trend<0.001), which was mainly attributed to a recent increment of NOAC-based triple therapy from 2013 (17.5% in 2015). Previous ischemic stroke or systemic embolism, old age, hypertension, and congestive heart failure were significantly associated with a higher triple therapy prescription rate, whereas previous myocardial infarction, PCI, and peripheral arterial disease were associated with triple therapy underuse.

Conclusions

From 2006 to 2015, the number of patients with AF undergoing PCI and the prescription rate of triple therapy increased gradually with a recent increment of NOAC-based antithrombotic therapy from 2013. Previous myocardial infarction, peripheral artery disease, and PCI were associated with underuse of triple therapy.

Effect of atrial fibrillation in Asian patients undergoing percutaneous coronary intervention with drug-eluting stents for stable coronary artery disease: Results from a Korean nationwide study

Although the prevalence of atrial fibrillation (AF) and percutaneous coronary intervention (PCI) are increasing in Asia, there is a paucity of data concerning the effect of AF in Asian patients undergoing PCI with drug-eluting stents (DESs). Furthermore, the majority of previous studies investigating the effect of AF on prognosis following PCI have exclusively evaluated patients with myocardial infarction (MI). We aimed to evaluate the effect of AF on clinical outcomes of Asian patients undergoing PCI with DES for coronary artery disease (CAD) excluding acute MI.From national health insurance claims data in South Korea, a total of 45,288 patients aged 18 years or older without a known history of CAD, who underwent PCI with DES for the diagnosis of CAD excluding acute MI between 2011 and 2015, were enrolled. Based on the presence or absence of a history of AF at baseline, patients were categorized into the AF group (n = 1715, 3.8%) and no-AF group (n = 43,573, 96.2%). Outcomes including all-cause death, the composite outcome of all-cause death/MI/coronary revascularization, and stroke were compared between 2 groups using a propensity-score-matched analysis.After propensity-score matching, 1709 matched pairs were obtained. During the follow-up period (mean, 2.2 years), the incidence of all-cause death (hazard ratio [HR] 1.117, 95% confidence interval [CI] 0.885-1.411, P = .35) and the composite outcome of all-cause death/MI/coronary revascularization (HR 1.004, 95% CI 0.846-1.192, P = .97) were not significantly different between 2 groups. However, the incidence of stroke was significantly increased in the AF group (HR 1.983, 95% CI 1.474-2.667, P < .001).In Asian patients undergoing PCI for stable CAD, a history of AF was not associated with mortality, but was associated with increased risk of stroke.

Antithrombotic Therapy After Percutaneous Coronary Intervention in Atrial Fibrillation: The Triple Trouble

One of the most common conundrums in all cardiovascular medicine pertains to the care of patients with atrial fibrillation after percutaneous coronary intervention, because of both dual antiplatelet therapy and oral anticoagulant therapy would seem to be necessary to reduce risks of stent thrombosis and thromboembolism, respectively, but also with an inevitable trade-off of more bleeding. Patients who require triple therapy are at high risk of both ischaemia and bleeding; therefore, defining a personalised secondary prevention strategy aimed at achieving the best net clinical benefit is essential. The good news is that we have entered an era of increased perceived and tangible safety that applies to both non-vitamin K-antagonist oral anticoagulants and newer drug-eluting stents. Even if the consistency across the major trials and the significantly lower risk of bleeding with dual therapy make it hard to argue that triple therapy should be used routinely, the aggregate evidence suggests that the net clinical benefit of dual therapy should give cardiologists confidence to drop aspirin when they are using a contemporary percutaneous coronary intervention strategy with drug-eluting stents. Waiting for more randomised trials and meta-analyses, for the time being, in patients not in clinical trials, full-dose oral triple therapy with dual antiplatelet agents and full-dose anticoagulation should be avoided as a routine practice, and the choice of the proper, that is, safer, oral anticoagulant, namely a non-vitamin K-antagonist oral anticoagulant, may be regarded by now as an additional bleeding avoiding strategy in patients with atrial fibrillation undergoing percutaneous coronary intervention.

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

BACKGROUND

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

CONCLUSIONS

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

Influence of Atrial Fibrillation on Outcomes in Patients Who Underwent Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Atrial fibrillation (AF) is a common co-morbidity among patients presenting with acute ST-segment elevation myocardial infarction (STEMI). Previously, small studies have reported an association between AF and poorer outcomes among patients with STEMI. We performed this study to investigate the impact of AF on in-hospital outcomes in patients with STEMI treated with primary percutaneous coronary intervention (PPCI) using a large national database. The study population constituted of patients 18 years and older with a primary discharge diagnosis of STEMI and who underwent PPCI. Using a 2:1 matching protocol, matched groups of patients with AF (N = 24,680) and without (N = 49,198) were developed. Among 1,493,859 patients with STEMI who underwent PPCI, 129,354 patients (8.7%) had AF. In the propensity-matched cohort, adjusted in-hospital mortality was significantly higher for patients with AF compared with patients with no AF (10.3% vs 9.4%) (adjusted odds ratio [OR] 1.10; confidence interval [CI] 1.06 to 1.16; p <0.0001). Patients with AF were also at higher risk of heart failure, cardiogenic shock, acute stroke, acute kidney injury, vascular complications, need for blood transfusion, and a composite outcome of gastrointestinal and retroperitoneal bleeding. Patients with AF were less likely to be treated with drug-eluting stent compared with patients without AF (51.4% vs 56.6%) (adjusted OR 0.81; CI 0.79 to 0.84; p <0.001). Among patients presenting with STEMI and who underwent PPCI, AF is present in about 8% of patients. In a propensity-matched analysis using a large national database, AF was found to be independently associated with a higher risk of in-hospital mortality and of other complications in these patients.

Antithrombotic therapy strategies for atrial fibrillation patients undergoing percutaneous coronary intervention: A systematic review and network meta-analysis

Objective

The aim of this systematic review and network meta-analysis was to evaluate the comparative efficacy and safety of antiplatelet agents, vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).

Methods

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched to identify clinical trials comparing antiplatelet drugs with VKA and NOACs or their combination in AF patients undergoing PCI with a mean/median follow-up of at least 12 months. A network meta-analysis was conducted to directly and indirectly compare the efficacy and safety of competitive antithrombotic regimens with a Bayesian random-effects model. Results were presented as relative risks (RRs) and 95% confidence intervals (CIs).

Results

A total of 15 studies enrolling 13,104 patients were included. Among 5 regimens, rivaroxaban 15 mg daily plus P2Y₁₂ inhibitor treatment demonstrated significant superiority over dual- and triple-antiplatelet therapies (DAPT, TT) in reducing thromboembolic events (0.64 [0.38, 0.95] and 0.68 [0.43, 0.98], respectively) but showed the maximum possibility of major bleeding risk, while VKA plus single antiplatelet therapy (SAPT) seemed the safest. Significantly less risk of major bleeding was seen in DAPT group than that in TT group (0.63 [0.39, 0.99]).

Conclusions

The present study suggests that combination of VKA and SAPT is the best choice for AF patients undergoing PCI considering both efficacy and safety. Rivaroxaban 2.5 mg twice daily plus DAPT treatment owns the highest probability to be the optimal alternative to VKA plus SAPT for these patients.

Contemporary Use of Oral Antithrombotic Agents: Focus on Dual and Triple Therapeutic Approaches

Atherosclerotic cardiovascular disease (ASCVD) represents a long-standing health care burden in most industrialized countries. Management of ASCVD is multifaceted, and utilization of antithrombotic agents is a key component of care to reduce vascular events. Minimizing thrombotic risk can be accomplished via antiplatelet or anticoagulant drugs; however, combination therapy is warranted for some indications. Although reducing thrombotic complications is important, it is equally vital to consider the safety of combination regimens. Thus clinicians must effectively balance both individualized thrombotic and bleeding risks when using this strategy. Scenarios occur in practice when determining the role for combination therapy is not clear, especially for patients with ASCVD who require both dual antiplatelet therapy plus anticoagulation. The aim of this review is to discuss the role of dual or triple antithrombotic therapies across the spectrum of thrombotic disease states. In addition to critiquing relevant research studies and evaluating key recommendations from nationally published guidelines and consensus statements involving the use of these agents, we offer practical considerations that can be utilized when managing patients with ASCVD.

Should We Still Have Bare-Metal Stents Available in Our Catheterization Laboratory?

The introduction of bare-metal stents (BMS) has represented a major advancement over plain old balloon angioplasty in the management of coronary artery disease. However, the high rates of target lesion revascularization associated with use of BMS have led to the development of drug-eluting stents, which require prolonged dual antiplatelet therapy due to the increased risk of late and very late stent thrombosis. The improvements in newer-generation drug-eluting stents have translated into better safety and efficacy compared with earlier generation and BMS, thus allowing shorter dual antiplatelet therapy duration. Here, we aim to provide reasons as to why we still need BMS in our cardiac catheterization laboratory.