Incidence and predictors of bleeding complications after percutaneous coronary intervention

Prognostic impact of heart failure admission in survivors of acute myocardial infarction

AIMS

The incidence and prognosis of symptomatic heart failure following acute myocardial infarction (AMI) in the primary percutaneous coronary intervention era have rarely been reported in the literature. This study aimed to (i) determine the incidence of heart failure admission among AMI survivors, (ii) compare 1 year outcomes between patients with heart failure admission and those without, and (iii) identify the independent risk factors associated with heart failure admission.

METHODS AND RESULTS

The Japan Acute Myocardial Infarction Registry is a prospective multicentre registry from which data on consecutively enrolled patients with AMI from 50 institutions between 2015 and 2017 were obtained. Among the 3411 patients enrolled, 3226 who survived until discharge were included in this study. The primary endpoint was all-cause mortality. The secondary endpoints were major adverse cardiovascular events (defined as cardiovascular mortality, non-fatal myocardial infarction, or non-fatal cerebral infarction) and major bleeding events corresponding to Bleeding Academic Research Consortium Type 3 or 5. Clinical outcomes were compared between the patients who were and were not admitted for heart failure. Over a median follow-up of 12 months, 124 patients (3.8%) were admitted due to heart failure. Independent risk factors for heart failure admission included older age, female sex, Killip class ≥2 on admission, left ventricular ejection fraction <40%, estimated glomerular filtration rate ≤30 mL/min/1.73 m2, a history of malignancy, and non-use of angiotensin-converting enzyme inhibitors at discharge. The cumulative incidence of all-cause mortality was significantly higher in the heart failure admission group than in the no heart failure admission group (11.3% vs. 2.5%, P < 0.001). The rates of major adverse cardiovascular events (16.9% vs. 2.7%, P < 0.001) and major bleeding (6.5% vs. 1.6%, P < 0.001) were significantly higher in the heart failure admission group. Heart failure admission was associated with a higher risk of all-cause mortality, even after adjusting for potential confounders (adjusted hazard ratio: 2.41, 95% confidence interval: 1.33-4.39, P = 0.004).

CONCLUSIONS

Utilizing real-world data of the contemporary percutaneous coronary intervention era from the Japan Acute Myocardial Infarction Registry database, this study demonstrates that the heart failure admission of AMI survivors was significantly associated with higher all-cause mortality rates.

Exploring factors associated with bleeding events after open heart surgery in patients on dialysis - effects of the presence or absence of warfarin therapy

BACKGROUND

Perioperative management of patients on dialysis is critical for controlling bleeding and thrombotic risk, in addition to infection control. Postoperative anticoagulation is often difficult to control, and different institutions have different policies. Therefore, in this study, we aimed to investigate factors associated with postoperative bleeding events and whether warfarin (WF) therapy affects the incidence of postoperative bleeding events, total mortality, and stroke.

METHODS

Patients who were admitted to the cardiovascular surgery department and underwent valve replacement or plasty were included, and those who underwent mechanical valve introduction were excluded. Thirty-nine patients were included in the study. The primary endpoint was to identify factors associated with the composite endpoint of postoperative bleeding events, and the secondary endpoint was to determine the effect size of WF therapy on postoperative bleeding events, all-cause mortality, and stroke and the strength of association between the crossed endpoints. The strength of the association between the crossed items was examined.

RESULTS

Low body weight (p = 0.038) was identified as a factor associated with the primary endpoint of postoperative bleeding events. The secondary endpoint of whether or not patients received WF therapy was largely unrelated to bleeding events, all-cause mortality, and postoperative stroke up to 90 days after surgery.

CONCLUSIONS

Preliminary studies suggest that low body weight is a risk factor for postoperative bleeding events in patients on dialysis, although further exploration of other factors will be necessary with the accumulation of similar cases.

The prevalence of bleeding after percutaneous coronary interventions: A systematic review and meta-analysis

BACKGROUND

Bleeding is a common complication associated with percutaneous coronary intervention (PCI). The aim of this study was to determine the prevalence of bleeding after PCI through a systematic review and meta-analysis.

METHODS

The systematic review and meta-analysis covered the period from 1989 to 2023. Multiple databases, including Embase, PubMed, Scopus, Web of Sciences (WoS), MagIran, Scientific Information Database (SID), and Google Scholar, were searched using validated keywords with MeSH and Emtree. The I2 index was used to check for heterogeneity among studies.

RESULTS

The review of 8 studies, with a sample size of 397,298 participants, showed high heterogeneity (I2: 97.8 %). Therefore, the random effects method was used to analyze the results. The prevalence of bleeding after intervention in percutaneous coronary arteries was reported to be 4.4 % (95%CI: 2-9.1).

CONCLUSION

This meta-analysis showed a significant prevalence of bleeding after PCI, highlighting the need for health policymakers to pay more attention to the complications associated with PCI. Interventional cardiologists should consider the effective factors in these bleeding and how to treat and control them due to the importance of this complication.

BNP level predicts bleeding event in patients with heart failure after percutaneous coronary intervention

OBJECTIVE

This study aimed to investigate the association between heart failure (HF) severity measured based on brain natriuretic peptide (BNP) levels and future bleeding events after percutaneous coronary intervention (PCI).

BACKGROUND

The Academic Research Consortium for High Bleeding Risk presents a bleeding risk assessment for antithrombotic therapy in patients after PCI. HF is a risk factor for bleeding in Japanese patients.

METHODS

Using an electronic medical record-based database with seven tertiary hospitals in Japan, this retrospective study included 7160 patients who underwent PCI between April 2014 and March 2020 and who completed a 3-year follow-up and were divided into three groups: no HF, HF with high BNP level and HF with low BNP level. The primary outcome was bleeding events according to the Global Use of Streptokinase and t-PA for Occluded Coronary Arteries classification of moderate and severe bleeding. The secondary outcome was major adverse cardiovascular events (MACE). Furthermore, thrombogenicity was measured using the Total Thrombus-Formation Analysis System (T-TAS) in 536 consecutive patients undergoing PCI between August 2013 and March 2017 at Kumamoto University Hospital.

RESULTS

Multivariate Cox regression showed that HF with high BNP level was significantly associated with bleeding events, MACE and all-cause death. In the T-TAS measurement, the thrombogenicity was lower in patients with HF with high BNP levels than in those without HF and with HF with low BNP levels.

CONCLUSIONS

HF with high BNP level is associated with future bleeding events, suggesting that bleeding risk might differ depending on HF severity.

Long-term outcomes of periprocedural coronary dissection and perforation for patients undergoing percutaneous coronary intervention in a Japanese multicenter registry

Long-term outcomes of iatrogenic coronary dissection and perforation in patients undergoing percutaneous coronary intervention (PCI) remains under-investigated. We analyzed 8,721 consecutive patients discharged after PCI between 2008 and 2019 from Keio Cardiovascular (KiCS) PCI multicenter prospective registry in the Tokyo metropolitan area. Significant coronary dissection was defined as persistent contrast medium extravasation or spiral or persistent filling defects with complete distal and impaired flow. The primary outcome was a composite of all-cause death, acute coronary syndrome, heart failure, bleeding, stroke requiring admission, and coronary artery bypass grafting two years after discharge. We used a multivariable Cox hazard regression model to assess the effects of these complications. Among the patients, 68 (0.78%) had significant coronary dissections, and 61 (0.70%) had coronary perforations at the index PCI. Patients with significant coronary dissection had higher rates of the primary endpoint and heart failure than those without (25.0% versus 14.3%, P = 0.02; 10.3% versus 4.2%, P = 0.03); there were no significant differences in the primary outcomes between the patients with and without coronary perforation (i.e., primary outcome: 8.2% versus 14.5%, P = 0.23) at the two-year follow-up. After adjustments, patients with coronary dissection had a significantly higher rate of the primary endpoint than those without (HR 1.70, 95% CI 1.02-2.84; P = 0.04), but there was no significant difference in the primary endpoint between the patients with and without coronary perforation (HR 0.51, 95% CI 0.21-1.23; P = 0.13). For patients undergoing PCI, significant coronary dissection was associated with poor long-term outcomes, including heart failure readmission.

Transradial intervention in dialysis patients undergoing percutaneous coronary intervention: a Japanese nationwide registry study

Aims

Transradial intervention (TRI) for percutaneous coronary intervention (PCI) is used to reduce periprocedural complications. However, its effectiveness and safety for patients on dialysis are not well established. We aimed to investigate the association of TRI with in-hospital complications in dialysis patients undergoing PCI.

Methods and results

We included 44 462 patients on dialysis who underwent PCI using Japanese nationwide PCI registry data (2019-21) regardless of acute or chronic coronary syndrome. Patients were categorized based on access site: TRI, transfemoral intervention (TFI). Periprocedural access site bleeding complication requiring transfusion was the primary outcome and in-hospital death, and other periprocedural complications were the secondary outcomes. Matched weighted analysis was performed for TRI and TFI. Here, 8267 (18.6%) underwent TRI, and 36 195 (81.4%) underwent TFI. Patients who received TRI were older and had lower rates of comorbidities than those who received TFI. Access site bleeding rate and in-hospital death were significantly lower in the TRI group (0.1% vs. 0.7%, P < 0.001; 1.8% vs. 3.2%, P < 0.001, respectively). After adjustment, TRI was associated with a lower risk of access site bleeding (odds ratio [OR] [95% confidence interval (CI)]: 0.19 [0.099-0.38]; P < 0.001) and in-hospital death (OR [95% CI]: 0.79 [0.65-0.96]; P = 0.02). Other periprocedural complications between TRI and TFI were not significantly different.

Conclusion

In patients undergoing dialysis and PCI, TRI had a lower risk of access site bleeding and in-hospital death than TFI. This suggests that TRI may be safer for this patient population.

Japanese high bleeding risk criteria status predicts low thrombogenicity and bleeding events in patients undergoing percutaneous coronary intervention

Although the Japanese high bleeding risk criteria (J-HBR) were established to predict bleeding risk in patients undergoing percutaneous coronary intervention (PCI), the thrombogenicity in the J-HBR status remains unknown. Here, we examined the relationships among J-HBR status, thrombogenicity and bleeding events. This study was a retrospective analysis of 300 consecutive patients who underwent PCI. Blood samples obtained on the day of PCI were used in the total thrombus-formation analysis system (T-TAS) to investigate the thrombus-formation area under the curve (AUC; PL₁₈-AUC₁₀ for platelet chip; AR₁₀-AUC₃₀ for atheroma chip). The J-HBR score was calculated by adding 1 point for any major criterion and 0.5 point for any minor criterion. We assigned patients to three groups based on J-HBR status: a J-HBR-negative group (n = 80), a low score J-HBR-positive group (positive/low, n = 109), and a high score J-HBR-positive group (positive/high, n = 111). The primary end point was the 1-year incidence of bleeding events defined by the Bleeding Academic Research Consortium types 2, 3, or 5. Both PL₁₈-AUC₁₀ and AR₁₀-AUC₃₀ levels were lower in the J-HBR-positive/high group than the negative group. Kaplan-Meier analysis showed worse 1-year bleeding event-free survival in the J-HBR-positive/high group compared with the negative group. In addition, both T-TAS levels in J-HBR positivity were lower in those with bleeding events than in those without bleeding events. In multivariate Cox regression analyses, the J-HBR-positive/high status was significantly associated with 1-year bleeding events. In conclusion, the J-HBR-positive/high status could reflect low thrombogenicity as measured by T-TAS and high bleeding risk in patients undergoing PCI.

Validation of Japanese Bleeding Risk Criteria in Patients After Percutaneous Coronary Intervention and Comparison With Contemporary Bleeding Risk Criteria

Background: The utility of the Japanese version of high bleeding risk (J-HBR) criteria compared with contemporary bleeding risk criteria, including Academic Research Consortium for High Bleeding Risk criteria, has not been fully investigated.

Methods and Results: This study included patients who underwent percutaneous coronary intervention between 2010 and 2019. The J-HBR score was calculated by assigning 1 point for each major criterion and 0.5 points for each minor criterion in the J-HBR criteria. Among 1,643 patients, 1,143 (69.6%) met the J-HBR criteria. Accumulated major bleeding event rates at 1 year were higher among those who met the J-HBR criteria (4.8% vs. 0.6%; P<0.001). J-HBR criteria had higher sensitivity (94.8%) and lower specificity (31.4%) than contemporary bleeding risk criteria in predicting major bleeding. Bleeding events increased with increasing J-HBR score. The C statistic for the J-HBR score for predicting major bleeding at 1 year was 0.75 (95% confidence interval 0.69–0.81), and is comparable to that of other risk scores. In multivariate analysis, of the factors included in J-HBR criteria, chronic kidney disease, heart failure, and active malignancy were associated with major bleeding.

Conclusions: J-HBR criteria identified patients at high bleeding risk with high sensitivity and low specificity. Bleeding risk was closely related to J-HBR score and its individual components. The discriminative ability of the J-HBR score was comparable to that of contemporary bleeding risk scores.

End-stage renal disease as an independent risk factor for in-hospital mortality after coronary drug-eluting stenting: Understanding and modeling the risk

OBJECTIVES

We sought to compare in-hospital outcomes between patients with and without end-stage renal disease (ESRD) undergoing coronary drug-eluting stent (DES) placement and to model risk of in-hospital adverse postpercutaneous coronary intervention (PCI) events in ESRD patients.

BACKGROUND

The effect of ESRD on the risk of in-hospital complications after DES PCI is relatively unclear, as is the ability to prospectively stratify risk in this population.

METHODS

Consecutive patients undergoing first-time DES between April 1, 2003 and June 30, 2018 at a single tertiary care hospital were included in a prospective registry. Outcomes in those with ESRD were compared to those without ESRD. The primary endpoint was in-hospital all-cause mortality; secondary endpoints included in-hospital major adverse cardiac events (MACE)-defined as cardiac death, myocardial infarction, or unplanned revascularization-and major bleeding. Multivariate logistic regression modeling was used to identify factors associated with each outcome and to generate risk scores.

RESULTS

Among 18,134 patients in the study population, 382 (2.1%) had ESRD. ESRD was associated with increased risk of in-hospital mortality (7.1 vs. 2.9%, p < .001), in-hospital MACE (6.3 vs. 2.1%, p < .001), and major bleeding (12.0 vs. 2.6%, p < .001). After multivariable risk adjustment, ESRD was independently associated with in-hospital mortality (odds ratio: 1.83, 95% confidence interval: 1.04-3.23, p = .04) but not MACE or major bleeding. Among patients with ESRD, risks of MACE and major bleeding were successfully modeled (c-statistics = .72 and .85, respectively).

CONCLUSIONS

ESRD is independently associated with increased risk of in-hospital mortality after coronary DES. Future studies are necessary to validate risk models derived to identify high-risk ESRD patients.

Is It Safe to Mobilize Patients Very Early After Transfemoral Coronary Procedures? (SAMOVAR): A Randomized Clinical Trial

BACKGROUND

Coronary angiography (CAG) and percutaneous coronary intervention (PCI) are performed via the femoral or radial arteries. In patients examined via transfemoral access, closure devices facilitate hemostasis, but it is unknown whether it is safe to mobilize these patients immediately and how acceptable this may be in terms of patient comfort.

OBJECTIVE

The aims of this study were to investigate bleeding complications in patients mobilized immediately after transfemoral CAG or PCI compared with patients on bed rest (BR) for 2 hours after the procedure and, furthermore, to investigate patient comfort in relation to mobilization and BR.

METHODS

SAMOVAR was a noninferiority trial with patients randomized to immediate mobilization (IM) or 2 hours of BR after transfemoral CAG or PCI and use of the AngioSeal as a closure device and reversal of heparin effect. The primary end point was development of hematoma greater than 5 cm, pseudoaneurysm, or bleeding requiring blood transfusion. Secondary end points were oozing from the puncture site, small hematoma, and patient comfort.

RESULTS

Of 2027 patients (IM, 1010; BR, 1017), 40% underwent PCI. The primary outcome was recorded in 0.7% patients randomized to IM versus 0.5% in BR (P = .58). There was no difference in the incidence of small hematoma, whereas persistent oozing was seen slightly more often after IM compared with BR (12% vs 9%, P = .04). Patients mobilized immediately reported less back pain and micturition problems (P < .001).

CONCLUSIONS

In patients who had CAG and PCI performed through transfemoral access, reversal of anticoagulation and use of closure devices allowed IM with low rates of complications and improved patient comfort.

Radial artery access is associated with lower mortality in patients undergoing primary PCI: a report from the SWEDEHEART registry

OBJECTIVES

The purpose of this observational study was to evaluate the effects of radial artery access versus femoral artery access on the risk of 30-day mortality, inhospital bleeding and cardiogenic shock in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

METHODS

We used data from the SWEDEHEART registry and included all patients who were treated with primary percutaneous coronary intervention in Sweden between 2005 and 2016. We compared patients who had percutaneous coronary intervention by radial access versus femoral access with regard to the primary endpoint of all-cause death within 30 days, using a multilevel propensity score adjusted logistic regression which included hospital as a random effect.

RESULTS

During the study period, 44,804 patients underwent primary percutaneous coronary intervention of whom 24,299 (54.2%) had radial access and 20,505 (45.8%) femoral access. There were 2487 (5.5%) deaths within 30 days, of which 920 (3.8%) occurred in the radial access and 1567 (7.6%) in the femoral access group. After propensity score adjustment, radial access was associated with a lower risk of death (adjusted odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55-0.88, P = 0.025). We found no interaction between access site and age, gender and cardiogenic shock regarding 30-day mortality. Radial access was also associated with a lower adjusted risk of bleeding (adjusted OR 0.45, 95% CI 0.25-0.79, P = 0.006) and cardiogenic shock (adjusted OR 0.41, 95% CI 0.24-0.73, P = 0.002).

CONCLUSIONS

In patients with ST-elevation myocardial infarction, primary percutaneous coronary intervention by radial access rather than femoral access was associated with an adjusted lower risk of death, bleeding and cardiogenic shock. Our findings are consistent with, and add external validity to, recent randomised trials.

Prevalence of the Japanese high bleeding risk criteria and its prognostic significance for fatal bleeding in patients with acute myocardial infarction

BACKGROUND

The Japanese high-bleeding-risk criteria (Japanese-HBR), modified criteria of the Academic Research Consortium (ARC) HBR, has been recently proposed. We aimed to investigate the prevalence of the ARC-HBR and the Japanese-HBR, and to assess their prognostic significance in patients with acute myocardial infarction (AMI).

METHODS AND RESULTS

We applied the ARC-HBR and the Japanese-HBR criteria to the OACIS prospective multicenter acute myocardial infarction registry (12,093 patients, 66 ± 12 years, 9,096 males). The primary endpoint was fatal bleeding (BARC-5). Median follow-up duration was 4.84 [inter-quartile range 1.35, 5.01] years. Prevalence of the ARC-HBR was 43.8%, while that of the Japanese-HBR was 61.8%. Cumulative incidence of fatal bleeding was higher in the ARC-HBR group than in the no ARC-HBR group at 1 year (1.3 vs. 0.6%) and at 5 years (2.0 vs. 0.7%). The Kaplan-Meier curves stratified by the Japanese-HBR criteria more prominently diverged (1.3 vs. 0.2% at 1 year; and 1.9 vs. 0.3% at 5 years). The Japanese-HBR criteria showed superior discriminative performance over the ARC-HBR criteria (C-statistics: 0.677 vs. 0.598, P < 0.001).

CONCLUSIONS

In the real-world Japanese AMI registry, nearly half of the patients fulfilled the criteria of ARC-HBR, and two-thirds met the Japanese-HBR. Our findings support the validity of both ARC- and Japanese-HBR criteria in AMI patients but encourage the future application of the Japanese-HBR criteria to the Japanese AMI cohort.

TRIAL REGISTRATION NUMBER

UMIN000004575.

Prevalence of the Academic Research Consortium high bleeding risk criteria in patients undergoing endovascular therapy for peripheral artery disease in lower extremities

The Academic Research Consortium (ARC) recently published a definition of patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention. However, the prevalence of the ARC-HBR criteria in patients undergoing endovascular therapy (EVT) for peripheral artery disease in lower extremities has not been thoroughly investigated. This study sought to investigate the prevalence and impact of the ARC-HBR criteria in patients undergoing EVT. We analyzed 277 consecutive patients who underwent their first EVT from July 2011 to September 2019. We applied the full ARC-HBR criteria to the study population. The primary end point was a composite outcome of all-cause mortality, Bleeding Academic Research Consortium 3 or 5 bleeding, and lower limb amputation within 12 months of EVT. Among the 277 patients, 193 (69.7%) met the ARC-HBR criteria. HBR patients had worse clinical outcomes compared with non-HBR patients at 12 months after EVT, including a higher incidence of the composite primary outcome (19.2% vs. 3.6%, p < 0.001) and all-cause death (7.8% vs. 0%, p = 0.007). In a multivariate Cox proportional hazards regression analysis, presence of the ARC-HBR criteria [hazard ratio (HR) 4.15, 95% confidence interval (CI) 1.25-13.80, p = 0.020], body mass index (HR 1.13, 95% CI 1.01-1.27, p = 0.042), diabetes mellitus (HR 2.70, 95% CI 1.28-5.69, p = 0.009), hyperlipidemia (HR 0.41, 95% CI 0.21-0.80, p = 0.009), and infrapopliteal lesions (HR 3.51, 95% CI 1.63-7.56, p = 0.001) were independent predictors of the primary composite outcome. Approximately 70% of Japanese patients undergoing EVT met the ARC-HBR criteria, and its presence was strongly associated with adverse outcomes within 12 months of EVT.

Implications and characteristics of high bleeding risk in East Asian patients undergoing percutaneous coronary intervention: Start with what is right rather than what is acceptable

Recent advances in percutaneous coronary intervention (PCI) technology and medication have changed the main focus of PCI from preventing ischemic to preventing bleeding events. Bleeding risk assessment is essential for preventing bleeding. Several types of assessment tools have been established, but they are heterogeneous, making interpretation, generalization, and comparison between trials difficult. In 2019, the Academic Research Consortium (ARC) introduced a new consensus document with 20 criteria to define high bleeding risk (HBR). The applicability of the ARCHBR criteria were subsequently investigated, and 4 studies have already demonstrated wide applicability worldwide, including in Japan. Nevertheless, it hase been suggested that bleeding risk is higher in people from East Asian countries than in people from Western countries. Patients with HBR have a 3-fold higher risk of major bleeding, and in Japan approximately 50% of patients undergoing PCI have HBR. In addition, patients with overlapping factors, such as older age, renal disease, and anemia, are at increased risk of bleeding, and each additional factor further increases the risk. In Japanese patients undergoing PCI, in addition to the ARC-HBR criteria, low body weight, heart failure, and peripheral arterial disease are high-risk subsets for bleeding. The addition of these factors to the ARCHBR criteria increases the prevalence of HBR in Japanese patients to 58% and improves the sensitivity of diagnostic evaluations. The additional factors are clinically important because they are often encountered in everyday practice, and Japan's newly updated guideline has adopted them as criteria for HBR. Studies found a temporal trend over the past 20 years of a gradual and consistent increase of bleeding risk. This finding contrasts with improved outcomes in people at risk of ischemic and thrombotic events. Therefore, further research is needed to eliminate the risk of bleeding while maintaining the efficacy of antithrombotic therapy after PCI.

Impact of Young Age and Gender on Outcomes of Transradial Versus Transfemoral Access Coronary Angiography

The differential impact of young age and female gender on transradial access (TRA) outcomes remains to be confirmed. The primary objective was to assess the impact of young age and female gender on in-hospital net adverse cardiovascular events (NACE). Among 12 346 patients from the Coronary Angiogram Database of South Australia (CADOSA) Registry, the impact of gender; men (transfemoral access [TFA] 1995, TRA 6168) and women (TFA 1249, TRA 2934), and a median split of age, ≤63 years (TFA 1617, TRA 4727) and >63 years (TFA 1627, TRA 4375) were analyzed on in-hospital outcomes by creating 5 separate propensity-matched cohorts (entire cohort, men, women, ≤63 and > 63 years). Net adverse cardiovascular event reduction with TRA was limited to the >63 years old cohort (odds ratio [OR] = 0.56, 95% CI: 0.34-0.93, P = .02) and women (OR = 0.37, 95% CI: 0.18-0.76, P = .007). In both the age groups and genders, TRA was associated with a lower risk of bleeding and all-cause mortality. On multivariate logistic regression, TRA was associated with a significant reduction in NACE, major bleeding, and mortality in the overall cohort. In conclusion, a reduction in bleeding and mortality was noted with TRA in all the subgroups in this observational study.

Development and Implementation of an In-Hospital Bleeding Risk Model for Percutaneous Coronary Intervention

BACKGROUND

Bleeding is a common complication of percutaneous coronary intervention (PCI) that is associated with worse clinical outcomes and increased costs. Improved pre-procedural bleeding risk prediction could promote strategies that have been shown to reduce post-PCI bleeding, including increased adoption of radial access.

METHODS

We studied patients in the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) program receiving PCI in VA hospitals. Logistic regression was performed to develop a model for major in-hospital bleeding using demographic, clinical, and procedural variables. The discriminatory ability of the model was compared to the existing National Cardiovascular Data Registry (NCDR) CathPCI bleeding risk model.

RESULTS

Among 107,451 patients treated from 2008 to 2019, 5218 (4.86%) experienced an in-hospital bleeding event. Twelve variables were associated with bleeding risk. Predictors of bleeding included emergency or salvage status, cardiogenic shock, NSTEMI, Atrial fibrillation, elevated INR, and peripheral vascular disease, while radial access, greater body surface area, and stable or unstable angina were associated with lower risk of bleeding. The developed model had superior discrimination compared with the NCDR CathPCI model (c-index 0.756, 95% CI 0.749-0.764 vs. 0.707, 95% CI 0.700-0.714, p < 0.001), especially among the highest risk patients. A web-based tool has been created to facilitate calculation of bleeding risk using this model at the point of care.

CONCLUSION

The VA CART bleeding risk model uses baseline clinical and procedural variables to predict post-PCI in-hospital bleeding events and has improved discrimination compared to other available models in this patient population. Implementation of this model can facilitate risk stratification at the point of care and permit improved risk-adjustment for quality assessment.

Complex Large-Bore Radial percutaneous coronary intervention: rationale of the COLOR trial study protocol

INTRODUCTION

The radial artery has become the standard access site for percutaneous coronary intervention (PCI) in stable coronary artery disease and acute coronary syndrome, because of less access site related bleeding complications. Patients with complex coronary lesions are under-represented in randomised trials comparing radial with femoral access with regard to safety and efficacy. The femoral artery is currently the most applied access site in patients with complex coronary lesions, especially when large bore guiding catheters are required. With slender technology, transradial PCI may be increasingly applied in patients with complex coronary lesions when large bore guiding catheters are mandatory and might be a safer alternative as compared with the transfemoral approach.

METHODS AND ANALYSIS

A total of 388 patients undergoing complex PCI will be randomised to radial 7 French access with Terumo Glidesheath Slender (Terumo, Japan) or femoral 7 French access as comparator. The primary outcome is the incidence of the composite end point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Procedural success and major adverse cardiovascular events up to 1 month will also be compared between both groups.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee at each recruiting center ('Medisch Ethische Toetsing Commissie Isala Zwolle', 'Commissie voor medische ethiek ZNA', 'Comité Medische Ethiek Ziekenhuis Oost-Limburg', 'Comité d'éthique CHU-Charleroi-ISPPC', 'Commission cantonale d'éthique de la recherche CCER-Republique et Canton de Geneve', 'Ethik Kommission de Ärztekammer Nordrhein' and 'Riverside Research Ethics Committee'). The trial outcomes will be published in peer-reviewed journals of the concerned literature.

TRIAL REGISTRATION NUMBER

NCT03846752.

Incidence and clinical outcomes of bleeding complications and acute limb ischemia in STEMI and cardiogenic shock

BACKGROUND

Bleeding complications and acute limb ischemia (ALI) are devastating vascular complications in patients with ST-segment elevation myocardial infarction (STEMI). Cardiogenic shock (CS) can further increase this risk due to multiorgan failure. In the contemporary era, percutaneous mechanical circulatory support is commonly used for management of CS. We hypothesized that vascular complications may be an important determinant of clinical outcomes for CS due to STEMI (CS-STEMI).

OBJECTIVE

We evaluated 10-year national trends, resource utilization and outcomes of bleeding complications, and ALI in CS-STEMI.

METHODS

We performed a retrospective cohort study of CS-STEMI patients from a large U.S. national database (National Inpatient Sample) between 2005 and 2014. Events were then divided into four different groups: no MCS, with intra-aortic balloon pump, percutaneous ventricular assist device includes Impella or Tandem Heart or extracorporeal membrane oxygenation.

RESULTS

Bleeding complications and ALI were observed in 31,389 (18.2%) and 1,628 (0.9%) out of 172,491 admissions with CS-STEMI, respectively. Between 2005 and 2014, overall trends increased for ALI; however, the number of bleeding events decreased. ALI was associated with increased in-hospital mortality in comparison to those without any ALI. However, bleeding complications were not associated with increased in-hospital mortality. Compared to patients without complications, both bleeding and ALI were associated with increased length of stay (LOS) and hospitalization costs.

CONCLUSIONS

Bleeding and ALI are common complications associated with CS-STEMI in the contemporary era. Both complications are associated with increased hospital costs and LOS. These findings highlight the need to develop algorithms focused on vascular safety in CS-STEMI.

Bleeding Severity in Percutaneous Coronary Intervention (PCI) and Its Impact on Short-Term Clinical Outcomes

Bleeding severity in patients undergoing percutaneous coronary intervention (PCI), defined by the Bleeding Academic Research Consortium (BARC), portends adverse prognosis. We analysed data from 37,866 Australian patients undergoing PCI enrolled in the Victorian Cardiac Outcomes Registry (VCOR), and investigated the association between increasing BARC severity and in-hospital and 30-day major adverse cardiac and cerebrovascular events (MACCE) (a composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularisation, or stroke). Independent predictors associated with major bleeding (BARC groups 3&5), and MACCE were also assessed. There was a stepwise increase in in-hospital and 30-day MACCE with greater severity of bleeding. Independent predictors of bleeding included female sex (Odds Ratio (OR) 1.34), age (OR 1.02), fibrinolytic therapy (OR 1.77), femoral access (OR 1.51), and ticagrelor (OR 1.42), all significant at the p < 0.001 level. Following adjustment of clinically important variables, BARC 3&5 bleeds (OR 4.37) were still predictive of cumulative in-hospital and 30-day MACCE. In conclusion, major bleeding is an uncommon but potentially fatal PCI complication and was independently associated with greater MACCE rates. Efforts to mitigate the occurrence of bleeding, including radial access and judicious use of potent antiplatelet therapies, may ameliorate the risk of short-term adverse clinical outcomes.

Vascular access management after percutaneous transluminal angioplasty using a calcium alginate sheet: a randomized controlled trial

BACKGROUND

Management of vascular access (VA) is essential in hemodialysis (HD) patients. However, VA often fails and percutaneous transluminal angioplasty (PTA) is required. Conventional hemostasis at the puncture site is associated with complications. This study aimed to analyze the efficacy and safety of a hemostatic wound dressing made of calcium alginate at the puncture site of VA after PTA and evaluate other factors affecting hemostasis.

METHODS

After PTA for VA, 200 HD patients were randomized to a calcium alginate sheet (CA) group (n = 100) or a no drug-eluting sheet (control) group (n = 100). We recorded time to hemostasis at the puncture site every 5 min, noting any complications.

RESULTS

In the CA group, rates of hemostatic achievement at 5, 10, 15 and >15 min were 57, 25, 8 and 10%, respectively. In the control group, the rates were 39, 28, 14 and 19%, respectively. Rates of hemostatic achievement at 5 min were significantly higher in the CA group (P = 0.01). In logistic regression analysis, factors affecting hemostasis within 5 min were use of the CA sheet [odds ratio (OR) 2.33; 95% confidence interval (CI) 1.26-4.37], platelet count ≤100 000/μL (OR 0.19; 95% CI 0.04-0.69), number of antithrombotic tablets used per day ≥1 tablet (OR 0.50; 95% CI 0.26-0.94) and upper arm VA (OR 0.16; 95% CI 0.03-0.55).

CONCLUSIONS

A CA sheet can safely reduce time to hemostasis at the puncture site after PTA, and should be considered for treating patients with a bleeding tendency.

Development of a percutaneous coronary intervention patient level composite measure for a clinical quality registry

BACKGROUND

Composite measures combine data to provide a comprehensive view of patient outcomes. Despite composite measures being a valuable tool to assess post-intervention outcomes, the patient perspective is often missing. The purpose of this study was to develop a composite measure for an established cardiac outcome registry, by combining clinical outcomes following percutaneous coronary interventions (PCI) with a patient-reported outcome measure (PROM) developed specifically for this population (MC-PROM).

METHODS

Two studies were undertaken. Study 1: Patients who had undergone a PCI at one of the three participating registry hospital sites completed the 5-item MC-PROM. Clinical outcome data for the patients (e.g. death, myocardial infarction, repeat vascularisation, new bleeding event) were collected 30 days post-intervention as part of routine data collection for the cardiac registry. Exploratory factor analysis of clinical outcomes and MC-PROM data was conducted to determine the minimum number of constructs to be included in a composite measure. Study 2: Clinical experts participated in a Delphi technique, consisting of three rounds of online surveys, to determine the clinical outcomes to be included and the weighting of the clinical outcomes and MC-PROM score for the composite measure.

RESULTS

Study 1: Routine clinical outcomes and the MC-PROM data were collected from 266 patients 30 days post PCI. The MC-PROM score was not significantly correlated with any clinical outcomes. Study 2: There was a relatively consistent approach to the weighting of the clinical outcomes and MC-PROM items by the expert panel (n = 18) across the three surveys with the exception of the clinical outcome of 'deceased at 30 days'. The final composite measure included five clinical outcomes within 30 days weighted at 90% (new heart failure, new myocardial infarction, new stent thrombosis, major bleeding event, new stroke, unplanned cardiac rehospitalisation) and the MC-PROM score (comprising 10% of the total weighting).

CONCLUSIONS

A single patient level composite score, which incorporates weighted clinical outcomes and a PROM was developed. This composite score provides a more comprehensive reported measure of individual patient wellbeing at 30 days post their PCI-procedure, and may assist clinicians to further assess and address patient level factors that potentially impact on clinical recovery.

Conventional vascular access site approach versus fully trans-wrist approach for chronic total occlusion percutaneous coronary intervention: a multicenter registry

OBJECTIVES

To evaluate the incidence of vascular complication and major bleeding in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with a fully trans-wrist access (TWA) approach versus a conventional approach based on trans-femoral access (TFA).

BACKGROUND

TFA is the preferred vascular access in CTO PCI, but it has been associated with a non-negligible risk of complications.

METHODS

This retrospective registry included all patients undergoing CTO PCI at five institutions between July 2011 and October 2018. Patients were divided into two groups: Conventional (patients treated with at least one TFA) and Fully TWA (subjects exclusively treated with one or two TWA). The primary safety endpoint was a composite of vascular complications and major bleeding. The primary efficacy endpoint was procedural success.

RESULTS

We included 1,900 patients (Conventional n = 1,496 and Fully TWA n = 404). Conventional patients showed higher occlusion complexity (J-CTO score 2.1 ± 1.2 vs. 1.5 ± 1.1, p < .001). Procedural success showed no significant difference between both groups (85.7 vs. 83.0%, p = .17). The primary safety endpoint occurred more frequently in the Conventional group (10.3 vs. 4.5%, p < .001), driven by vascular complications (9.4 vs. 3.7%, p < .001). On multivariate analysis, not using a Fully TWA approach was an independent predictor of the study endpoint, after adjusting for age, sex, diabetes, body mass index, chronic kidney disease, prior coronary artery bypass graft, and J-CTO score.

CONCLUSIONS

Embracing a Fully TWA approach for CTO PCI might be associated with lower incidence of a composite endpoint of vascular complications and major bleeding, compared with a Conventional approach.

Temporal trends in bleeding events in acute myocardial infarction: insights from the SWEDEHEART registry

Aims

To describe the time trends of in-hospital and out-of-hospital bleeding parallel to the development of new treatments and ischaemic outcomes over the last 20 years in a nationwide myocardial infarction (MI) population.

Methods and results

Patients with acute MI (n = 371 431) enrolled in the SWEDEHEART registry from 1995 until May 2018 were selected and evaluated for in-hospital bleeding and out-of-hospital bleeding events at 1 year. In-hospital bleeding increased from 0.5% to a peak at 2% 2005/2006 and thereafter slightly decreased to a new plateau around 1.3% by the end of the study period. Out-of-hospital bleeding increased in a stepwise fashion from 2.5% to 3.5 % in the middle of the study period and to 4.8% at the end of the study period. The increase in both in-hospital and out-of-hospital bleeding was parallel to increasing use of invasive strategy and adjunctive antithrombotic treatment, dual antiplatelet therapy (DAPT), and potent DAPT, while the decrease in in-hospital bleeding from 2007 to 2010 was parallel to implementation of bleeding avoidance strategies. In-hospital re-infarction decreased from 2.8% to 0.6% and out-of-hospital MI decreased from 12.6% to 7.1%. The composite out-of-hospital MI, cardiovascular death, and stroke decreased in a similar fashion from 18.4% to 9.1%.

Conclusion

During the last 20 years, the introduction of invasive and more intense antithrombotic treatment has been associated with an increase in bleeding events but concomitant there has been a substantial greater reduction of ischaemic events including improved survival.

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.

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.

Gender-related differences in men and women with ST-segment elevation myocardial infarction and incomplete infarct-related artery flow restoration: a multicenter national registry

INTRODUCTION

Little is known about gender-related differences in ST-segment elevation myocardial infarction (STEMI) and incomplete infarct-related artery (IRA) reperfusion after primary percutaneous coronary intervention (pPCI).

AIM

To evaluate gender-related differences in clinical characteristics and prognosis in patients with STEMI and incomplete IRA reperfusion after pPCI.

MATERIAL AND METHODS

From 42,752 STEMI patients hospitalized between 2009 and 2011 in Poland we analyzed a group of 984 (36%) females and 1,746 (64%) males with less than Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow following pPCI.

RESULTS

Women were older than men (72.0 ±11.3 vs. 64.0 ±11.7 years; p < 0.0001) and in age-adjusted analysis they were more likely to present with hypertension (73.7% vs. 67%; p = 0.0003), diabetes (33% vs. 22.6%; p < 0.0001) and obesity (28.1% vs. 22.6%; p = 0.0016). Heart rate > 100 beats/min was more common in women, while men were more often smokers and presented with sudden cardiac arrest. The most common IRA in women was the left anterior descending artery, and the right coronary artery in men. After adjusting for age statistically significant differences in pharmacotherapy concerned only the use of insulin (OR = 1.31, 95% CI: 1.02-1.68). High risk of death, rehospitalization due to heart failure or cardiac causes, were observed in all patients during the 6-month and 12-month follow-up periods. The risk of heart failure was significantly higher in women than in men. The most significant decrease in survival rates was observed in the in-hospital period.

CONCLUSIONS

Among patients with STEMI and post-interventional TIMI flow grade < 3 women have unfavorable baseline characteristics and an adverse short- and long-term prognosis when compared to men.

An overview of percutaneous coronary intervention in dialysis patients: Insights from a Japanese nationwide registry

OBJECTIVES

This study sought to provide an overview of percutaneous coronary intervention (PCI) in dialysis patients from a Japanese nationwide registry.

BACKGROUND

Little is known about dialysis patients undergoing PCI because few are enrolled in clinical trials.

METHODS

We analyzed 624,900 PCI cases including 41,384 dialysis patients (6.6%) from 1,017 Japanese hospitals between 2014 and 2016. We investigated differences in characteristics and in-hospital outcomes between dialysis and nondialysis patients, and assessed factors associated with an increased risk of adverse outcomes.

RESULTS

Dialysis patients had more comorbidities than nondialysis patients and higher rates of complications including in-hospital mortality (3.3% vs. 1.5%, respectively, in the acute coronary syndrome [ACS] cohort, 0.2% vs. 0.1% in the non-ACS cohort) and bleeding complications requiring blood transfusion (1.1% vs. 0.4% in ACS, 0.5% vs. 0.2% in non-ACS). Dialysis was significantly associated with an increased risk of in-hospital mortality (odds ratio [OR]: 1.42, 95% confidence interval [CI]: 1.24-1.62 in ACS, OR: 2.25, 95% CI: 1.66-3.05 in non-ACS) and bleeding (OR: 1.60, 95% CI: 1.30-1.96 in ACS, OR: 1.55, 95% CI: 1.27-1.88 in non-ACS). For dialysis patients, age, acute heart failure, and cardiogenic shock were associated with an increased risk of in-hospital mortality in the ACS cohort, whereas age, female gender, and history of heart failure were associated with higher in-hospital mortality in the non-ACS cohort.

CONCLUSIONS

PCI was widely performed for dialysis patients with either ACS or non-ACS in Japan. Dialysis patients had a greater risk of adverse outcomes than nondialysis patients after PCI.

Impact of catheter-induced iatrogenic coronary artery dissection with or without postprocedural flow impairment: A report from a Japanese multicenter percutaneous coronary intervention registry

Despite the ever-increasing complexity of percutaneous coronary intervention (PCI), the incidence, predictors, and in-hospital outcomes of catheter-induced coronary artery dissection (CICAD) is not well defined. In addition, there are little data on whether persistent coronary flow impairment after CICAD will affect clinical outcomes. We evaluated 17,225 patients from 15 participating hospitals within the Japanese PCI registry from January 2008 to March 2016. Associations between CICAD and in-hospital adverse cardiovascular events were evaluated using multivariate logistic regression. Outcomes of patients with CICAD with or without postprocedural flow impairment (TIMI flow ≤ 2 or 3, respectively) were analyzed. The population was predominantly male (79.4%; mean age, 68.2 ± 11.0 years); 35.6% underwent PCI for complex lesions (eg. chronic total occlusion or a bifurcation lesion.). CICAD occurred in 185 (1.1%), and its incidence gradually decreased (p < 0.001 for trend); postprocedural flow impairment was observed in 43 (23.2%). Female sex, complex PCI, and target lesion in proximal vessel were independent predictors (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.53–3.10; OR, 2.19; 95% CI, 1.58–3.04; and OR, 1.55; 95% CI, 1.06–2.28, respectively). CICAD was associated with an increased risk of in-hospital adverse events (composite of new-onset cardiogenic shock and new-onset heart failure) regardless of postprocedural flow impairment (OR, 10.9; 95% CI, 5.30–22.6 and OR, 2.27; 95% CI, 1.20–4.27, respectively for flow-impaired and flow-recovered CICAD). In conclusion, CICAD occurred in roughly 1% of PCI cases; female sex, complex PCI, and proximal lesion were its independent risk factors. CICAD was associated with adverse in-hospital cardiovascular events regardless of final flow status. Our data implied that the appropriate selection of PCI was necessary for women with complex lesions.

Relation of Baseline Hemoglobin Level to In-Hospital Outcomes in Patients Who Undergo Percutaneous Coronary Intervention (from a Japanese Multicenter Registry)

Scarce data exist regarding the relation between baseline hemoglobin and in-hospital outcomes after percutaneous coronary intervention (PCI). We studied 13,010 cases of PCI in a Japanese multicenter registry from 2008 to 2016. Patients were divided into 5 groups according to 2-g/dl increments in their preprocedural hemoglobin (from <10 to >16 g/dl). Patients with lower hemoglobin levels were older and had higher proportions of females and co-morbidities, including diabetes mellitus and renal failure, than those with higher hemoglobin levels. In-hospital complications were observed more frequently in patients with lower than higher levels. After adjustment, baseline hemoglobin was inversely associated with total procedural complications (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.84 to 0.90, p <0.001), in-hospital mortality (OR 0.82, 95% CI 0.77 to 0.87, p <0.001), and bleeding complications (OR 0.93, 95% CI 0.88 to 0.98, p = 0.007). Categorically, reverse J-shaped curvilinear correlations were present between baseline hemoglobin and in-hospital adverse outcomes. When the reference group comprised patients with a baseline hemoglobin of 12 to 14 g/dl, patients within the lowest hemoglobin levels (<10 g/dl) were at the highest risk of total procedural complications (OR 2.57, 95% CI 2.07 to 3.17, p <0.001), in-hospital mortality (OR 3.46, 95% CI 2.34 to 5.11, p <0.001), and bleeding complications (OR 2.36, 95% CI 1.70 to 3.25, p <0.001). In subgroup analyses, similar trends were observed in both men and women, and in both patients with acute coronary syndrome and stable coronary artery disease. In conclusion, a low baseline hemoglobin is a simple and powerful predictor of poor outcomes in patients who undergo PCI.

Ability of the prognostic model of J-ACCESS study to predict cardiac events in a clinical setting: The APPROACH study

BACKGROUND

In patients with coronary artery disease (CAD), one of the risk models available in Japan was a multivariate risk prediction model based on a Japanese multicenter database: the Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT (J-ACCESS). The aim of this study was to clinically validate the accuracy of this risk model.

METHODS

We evaluated the performance of the J-ACCESS model using data derived from the Assessment of the Predicted value of PROgnosis of cArdiaC events in Hokuriku (APPROACH) registry. Variables of age, summed stress score (SSS), left ventricular ejection fraction (LVEF), estimated glomerular filtration rate (eGFR), and diabetes mellitus were included. The major cardiac events were defined as cardiac death, non-fatal myocardial infarction, and heart failure that required hospitalization. The patients were followed up for three years to compare between predicted risk and actual events.

RESULTS

We evaluated 283 patients with suspected or confirmed CAD receiving myocardial perfusion imaging using ^99mTc-tetrofosmin between March 2009 and August 2011. Mean age was 68.9±10.1 years, mean eGFR 67.4±24.3mL/min/1.73m², mean SSS 5.2±7.2, and mean LVEF 65.4±14.0%. Fourteen (4.9%) patients experienced major cardiac events including cardiac death in 4 patients (1.4%), non-fatal myocardial infarction in 1 patient (0.3%), and severe heart failure in 9 patients (3.2%), respectively. While SSS≥8, LVEF<50%, eGFR<45mL/min/1.73m², and event risk≥10% were significant variables in survival analysis, multivariate proportional hazard analysis showed that only LVEF and eGFR were significant. The event rate estimated from the J-ACCESS model was comparable to the actual number of major cardiac events (9 and 6, respectively, p=0.58 by Chi-square test).

CONCLUSIONS

The predictive ability of the J-ACCESS risk model is clinically valid among patients with CAD and could be applicable in clinical practice.