Sirolimus-Eluting Coronary Stents in Octogenarians

The influence of Elixhauser comorbidity index on percutaneous coronary intervention outcomes

BACKGROUND

Clinical outcomes with respect to the evolution of comorbidity burden in national cohorts of patients undergoing PCI have not been reported.

OBJECTIVES

We sought to explore the association between comorbidity burden and periprocedural outcomes in patients treated with PCI in the National Inpatient Sample.

METHODS

6,601,526 PCI procedures were identified between 2004 and 2014 and comorbidities were defined by the Elixhauser classification system (ECS) consisting of 30 comorbidity measures. Endpoints included in-hospital mortality, periprocedural complications, length of stay and cost. Patients were classified based on their ECS in five categories (ECS I < 0, ECS II = 0, ECS III = 1-5, ECS IV = 6-13, and ECS V ≥ 14).

RESULTS

Patients with a score over 13 had a fivefold increase in the odds of mortality (OR: 5.13, 95% CI: 4.76-5.54), major bleeding (OR: 11.46, 95% CI: 10.66-12.33) and doubled the hospitalization costs ($31,452 vs $17.566).

CONCLUSIONS

Our study of over six million PCI procedures demonstrates that patients with the greatest comorbid burden (as defined by an ECS of >13) have a fivefold increase risk of in-hospital mortality, a fourfold increase in in-hospital periprocedural complications and an 11-fold increase in major bleeding events once differences in baseline patient characteristics are adjusted for. In addition, ECS significantly impacts the length of stay and doubles the healthcare costs. Comorbid burden is an important predictor of poor outcomes after PCI and should be considered as part of the decision-making processes in patients undergoing PCI.

Impact of co-morbid burden on mortality in patients with coronary heart disease, heart failure, and cerebrovascular accident: a systematic review and meta-analysis

Aims

We sought to investigate the prognostic impact of co-morbid burden as defined by the Charlson Co-morbidity Index (CCI) in patients with a range of prevalent cardiovascular diseases.

Methods and results

We searched MEDLINE and EMBASE to identify studies that evaluated the impact of CCI on mortality in patients with cardiovascular disease. A random-effects meta-analysis was undertaken to evaluate the impact of CCI on mortality in patients with coronary heart disease (CHD), heart failure (HF), and cerebrovascular accident (CVA). A total of 11 studies of acute coronary syndrome (ACS), 2 stable coronary disease, 5 percutaneous coronary intervention (PCI), 13 HF, and 4 CVA met the inclusion criteria. An increase in CCI score per point was significantly associated with a greater risk of mortality in patients with ACS [pooled relative risk ratio (RR) 1.33; 95% CI 1.15-1.54], PCI (RR 1.21; 95% CI 1.12-1.31), stable coronary artery disease (RR 1.38; 95% CI 1.29-1.48), and HF (RR 1.21; 95% CI 1.13-1.29), but not CVA. A CCI score of >2 significantly increased the risk of mortality in ACS (RR 2.52; 95% CI 1.58-4.04), PCI (RR 3.36; 95% CI 2.14-5.29), HF (RR 1.76; 95% CI 1.65-1.87), and CVA (RR 3.80; 95% CI 1.20-12.01).

Conclusion

Increasing co-morbid burden as defined by CCI is associated with a significant increase in risk of mortality in patients with underlying CHD, HF, and CVA. CCI provides a simple way of predicting adverse outcomes in patients with cardiovascular disease and should be incorporated into decision-making processes when counselling patients.

Favorable outcomes in octogenarians treated with bioresorbable polymer drug-eluting stent

AIM

As a result of a higher prevalence of comorbidities, elderly adults are often underrepresented in clinical trials, and more often experience complications during percutaneous coronary intervention. Our aim was to evaluate clinical outcomes of patients older than 80 years, compared with their younger counterparts, when bioresorbable polymer biolimus A9 drug-eluting stent is used for their treatment.

METHODS

The prospective, observational e-Nobori registry was created to validate the safety and efficacy of bioresorbable polymer drug-eluting stent in unselected patients. The primary end-point of the study was freedom from target lesion failure defined as a composite of cardiac death, target vessel-related myocardial infarction and clinically-driven target lesion revascularization at 1 year.

RESULTS

There were 781 (7.8%) octogenarians, they were less frequently male (62% vs 77%; P < 0.0001) and more often presented as acute coronary syndrome (44% vs 39%; P = 0.0182). The index percutaneous coronary intervention success was lower in the elderly patients (98% vs 99%; P = 0.0398). One-year follow up was completed for 97% of the elderly patients and 99% of the younger patients. The difference in target lesion failure (3.33% vs 2.83%; log-rank P = 0.0114) was mainly driven by increased mortality in octogenarians (3.73% vs 1.47%; P < 0.0001). Elderly patients had more bleeding and vascular complications (2.67% vs 1.05%; P = 0.0001).

CONCLUSIONS

Despite advanced age, multiple comorbidities and complexity of treated lesions, clinical outcomes are favorable in octogenarians treated by bioresorbable polymer biolimus A9 drug-eluting stent. Geriatr Gerontol Int 2016; 16: 1246-1253.

Drug eluting stent implantation in patients requiring concomitant vitamin K antagonist therapy. One-year outcome of the worldwide e-SELECT registry

BACKGROUND

Outcome of sirolimus-eluting stent (SES) in patients treated with an antivitamin K (VKA) agent before the PCI procedure is unknown.

METHODS

A total of 7651 patients were selected among 15,147 recipients of SES, included in the worldwide e-SELECT registry, only from those centers which included at least one patient requiring VKA: 296 were pretreated with a VKA agent (VKA group), whereas 7355 patients from the same enrolling medical centers were not (NON-VKA group). The rates of 1) major adverse cardiac events (MACE), including all-cause deaths, myocardial infarction (MI) and target lesion revascularization, 2) stent thrombosis (ST) and 3) major bleeding (MB) in the 2 study groups were compared at 1, 6 and 12 months.

RESULTS

The patients in VKA group were on average older as compared to those in NON-VKA group (67.7 ± 9.9 vs.62.9 ± 10.7, P<0.001). The indications for pre-procedural anticoagulation were atrial fibrillation in 177 (59.8%), presence of a prosthetic valve in 21 (7.1%), embolization of cardiac origin in 17 (5.7%), pulmonary embolism or deep vein thrombosis in 17 (5.7%), and miscellaneous diagnoses in 64 (21.6%) patients. At 1 year, the rates of MACE and MB were higher in the VKA vs. the NON-VKA group (8.3% and 3% vs. 5.3% and 1.2%, P<0.04 and P<0.002, respectively). The 1-year rates of definite and probable ST were remarkably low in both groups (0.38% vs. 1.1%, p=0.4).

CONCLUSIONS

Selected patients anticoagulated with VKA agent may safely undergo SES implantation. Those patients may receive a variety of APT regimen at the cost of a moderate increased risk of MB.

Comparison of clinical outcomes between octogenarians and non-octogenarians with acute myocardial infarction in the drug-eluting stent era: analysis of the Korean Acute Myocardial Infarction Registry

BACKGROUND AND PURPOSE

Octogenarians (age ≥ 80 years) with coronary artery disease constitute a high-risk group. However, octogenarian patients with acute myocardial infarction (AMI) in the drug-eluting stents (DES) era have not been widely reported. We aimed to identify clinical outcomes in octogenarian compared with non-octogenarian AMI patients.

METHODS AND SUBJECTS

We retrospectively analyzed 9877 patients who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and who were enrolled in the Korean Acute Myocardial Infarction Registry (KAMIR). They were divided into 2 groups, octogenarians (n=1494) and non-octogenarians (n=8383), in order to compare the incidence of 1-year all-cause death and 1-year major adverse cardiac events (MACE), where MACE included all-cause death, recurrent myocardial infarction, target vessel revascularization (TVR), target lesion revascularization (TLR), and coronary artery bypass grafting (CABG).

RESULTS

The clinical status was significantly inferior in octogenarians compared to non-octogenarians: Killip class ≥ II (34.8% vs. 22.5%, p<0.001), multivessel disease (65.8% vs. 53.7%, p<0.001). Rates of 1-year all-cause death were significantly higher in octogenarians than in non-octogenarians (22.3% vs. 6.5%, p<0.001). However, the rates of 1-year recurrent myocardial infarction (1.3% vs. 0.9%, p=0.68), TLR (2.4% vs. 3.1%, p=0.69), TVR (3.6% vs. 4.3%, p=0.96), and CABG (0.9% vs. 0.9%, p=0.76) did not differ significantly between the 2 groups.

CONCLUSIONS

Octogenarian AMI patients have higher rates of mortality and MACE even in the DES era. According to KAMIR subgroup analysis, the TLR/TVR rates in octogenarians were comparable to those in non-octogenarian AMI patients.

One-year outcome of small-vessel disease treated with sirolimus-eluting stents: a subgroup analysis of the e-SELECT registry

OBJECTIVES

To investigate the characteristics and one-year outcomes following sirolimus-eluting CYPHER Select Plus stent (SES) implantation in small (SmVD) and non-small vessel disease (NSmVD) in the international e-SELECT registry.

BACKGROUND

Large-scale registry data are lacking on DES outcomes in SmVD treatment.

METHODS

There were 4,700 SmVD (at least one vessel with estimated reference vessel diameter [RVD] < 2.5 mm, excluding 283 patients with unknown RVD vessels) and 10,139 NSmVD only patients.

RESULTS

The SmVD population was older, with more women, diabetics, and vessels treated, higher mean Charlson Comorbidity Index score (CCI), shorter lesions, and less STEMI presentation. The 1-year stent thrombosis (ST) rate (primary end-point), was significantly higher (1.3% vs. 0.7%) in SmVD versus NSmVD, mainly driven by early events. One-year major adverse cardiac event (MACE), myocardial infarction (MI), and clinically indicated target-lesion revascularization (TLR) rates were significantly higher in SmVD although death and major bleeding rates were similar in both groups. Complication rates were similar between pure (3,188 patients; only RVD < 2.5 mm) and mixed (1,795 patients; some RVD < 2.5 mm or unknown RVD) SmVD. Multivariate predictors for 1-year MACE in SmVD included saphenous vein graft or bifurcation lesions, major bleeding, any antiplatelet therapy discontinuation within 1 month, age, number of stents implanted, CCI, acute coronary syndrome, and insulin-dependent diabetes mellitus.

CONCLUSION

SES implantation for SmVD occurs more frequently in women, diabetics, and those with multivessel disease and comorbidities. One-year ST, MACE, MI, and clinically indicated TLR rates are higher, although low overall, in SmVD or mixed SmVD patients while death rates are similar to NSmVD.