Development and Validation of an Ischemic and Bleeding Risk Evaluation Tool in East Asian Patients Receiving Percutaneous Coronary Intervention

Efficacy of Percutaneous Coronary Intervention With Synergy Stents in Patients Aged ≥75 Years: 1-Year Clinical Outcomes from the Synergy Elderly Registry

Data regarding the clinical outcomes of older patients after Synergy everolimus-eluting stent (S-EES) implantation are limited. This study investigated the 12-month clinical outcomes of older patients who underwent percutaneous coronary intervention with new-generation drug-eluting stents according to ischemic risks. This prospective multicenter study targeted patients aged ≥75 years who underwent S-EES implantation. The primary and secondary end points included 12-month device-oriented composite end point (DOCE) (cardiovascular death, target vessel myocardial infarction, or target lesion revascularization) and major adverse cardiac and cerebrovascular events (MACCEs; all-cause death, myocardial infarction, target vessel revascularization, stent thrombosis, or stroke), respectively. A stratified analysis was conducted according to high-ischemic risk (HIR), defined as complex coronary intervention (number of stents implanted ≥3, total stented length >60 mm, chronic total occlusion, left main, or bifurcation), diabetes, or chronic kidney disease. In total, 650 enrolled patients aged ≥75 years were categorized into HIR (n = 425) and non-HIR groups (n = 225). In the total population, the 1-year incidence of DOCEs was 2.5%. The rates of DOCEs were not significantly different between the HIR and the non-HIR groups, whereas the MACCE rate was higher in the HIR (9.4%) than the non-HIR group (4.9%, p = 0.035), and the DOCE and MACCE components did not differ significantly in the occurrence between the groups. The independent predictors for the DOCEs or MACCEs included age, anemia, or left ventricular ejection fraction <40%. In conclusion, in older patients, S-EES implantation demonstrated favorable device-related outcomes, regardless of procedural complexity or co-morbidities. However, it requires careful attention because older patients with HIR are associated with worse clinical outcomes.

Individual acute-phase bleeding and thrombotic risk balance assessment in patients undergoing percutaneous coronary intervention for acute myocardial infarction

Background

Individualized treatment approach based on pre-procedural precise risk balance assessment between bleeding and thrombosis would be desirable for patients with myocardial infarction (MI) undergoing emergent percutaneous coronary intervention (PCI) in this ultra-short dual antiplatelet therapy era. We aimed to develop and validate a quick thrombosis/bleeding risk-balance assessment tool.

Methods

We developed and validated a novel thrombosis/bleeding risk-balance assessment tool using individual patient data from the prospective multicenter MI registry. Individual risks of thrombosis and bleeding within 7 days of the index PCI were estimated using a multinomial logistic regression model. The model was developed in the derivation cohort (4554 patients enrolled during 2003-2009) and validated in the validation cohort (2215 patients during 2010-2014).

Results

A total of 6769 patients (66 ± 12 years, 5175 men) were eligible in this analysis. Predictive performance of the multinomial logistic regression models for bleeding and thrombosis assessed by calibration plots was good both in the derivation and validation cohorts. The net predicted probability (NPP) was defined as predicted probability of bleeding event (%) - predicted probability of thrombotic event (%). The NPP successfully stratified patients into those with a higher risk of bleeding than thrombosis and those with a higher risk of thrombosis than bleeding. This finding was consistent between the derivation and validation cohorts.

Conclusions

We have established the risk balance assessment model for bleeding and thrombosis. Pre-procedural quick and precise assessment of the risk balance may help a decision making of procedural strategy and antithrombotic regimens in STEMI/non-STEMI patients undergoing PCI.

Incidence, Prediction, and Outcomes of Major Bleeding After Percutaneous Coronary Intervention in Chinese Patients

BACKGROUND

The patterns of late major bleeding (MB) after percutaneous coronary intervention (PCI) remain unknown in Chinese patients.

OBJECTIVES

This study sought to determine the incidence, prediction, and long-term outcomes of late MB in Chinese patients.

METHODS

This was a retrospective cohort study from 14 hospitals in Hong Kong. Participants were patients undergoing first-time PCI without MB within 30 days or death within 1 year. Patients were stratified by the presence of late MB, defined as MB between 30 and 365 days. The primary endpoint was all-cause mortality. The secondary endpoints were major adverse cardiac events (MACE).

RESULTS

A total of 32,057 patients were analyzed. After adjustment for baseline characteristics, periprocedural characteristics, and medications on discharge, the risks of all-cause mortality at 5 years were significantly higher with late MB (HR: 2.15; 95% CI: 1.92-2.41; P < 0.001). Late MB was also associated with a higher risk of MACE (HR: 1.57; 95% CI: 1.03-1.50; P < 0.001), myocardial infarction (HR: 1.25; 95% CI: 1.04-1.52; P = 0.02), and stroke (HR: 1.38; 95% CI: 1.09-1.73; P = 0.006). The CARDIAC (anti-Coagulation therapy, Age, Renal insufficiency, Drop In hemoglobin, baseline Anemia in Chinese patients) score had a good discriminating power for prediction of MB within 365 days (area under the receiver-operating characteristic curve: 0.76).

CONCLUSIONS

Late MB was independently associated with a higher risk of mortality, MACE, myocardial infarction, and stroke in patients undergoing PCI. The CARDIAC score is a simple model that can predict MB after PCI. Prevention of MB represents an important strategy to optimize cardiovascular outcomes for patients undergoing PCI.

Prasugrel-based De-Escalation of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With STEMI

BACKGROUND AND OBJECTIVES

De-escalation of dual-antiplatelet therapy through dose reduction of prasugrel improved net adverse clinical events (NACEs) after acute coronary syndrome (ACS), mainly through the reduction of bleeding without an increase in ischemic outcomes. Whether the benefits of de-escalation are sustained in highly thrombotic conditions such as ST-elevation myocardial infarction (STEMI) is unknown. We aimed to assess the efficacy and safety of de-escalation therapy in patients with STEMI or non-ST-segment elevation ACS (NSTE-ACS).

METHODS

This is a pre-specified subgroup analysis of the HOST-REDUCE-POLYTECH-ACS trial. ACS patients were randomized to prasugrel de-escalation (5 mg daily) or conventional dose (10 mg daily) at 1-month post-percutaneous coronary intervention. The primary endpoint was a NACE, defined as a composite of all-cause death, non-fatal myocardial infarction, stent thrombosis, clinically driven revascularization, stroke, and bleeding events of grade ≥2 Bleeding Academic Research Consortium (BARC) criteria at 1 year.

RESULTS

Among 2,338 patients included in the randomization, 326 patients were diagnosed with STEMI. In patients with NSTE-ACS, the risk of the primary endpoint was significantly reduced with de-escalation (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.48-0.89; p=0.006 for de-escalation vs. conventional), mainly driven by a reduced bleeding. However, in those with STEMI, there was no difference in the occurrence of the primary outcome (HR, 1.04; 95% CI, 0.48-2.26; p=0.915; p for interaction=0.271).

CONCLUSIONS

Prasugrel dose de-escalation reduced the rate of NACE and bleeding, without increasing the rate of ischemic events in NSTE-ACS patients but not in STEMI patients.

Antithrombotic Therapy After Acute Coronary Syndromes or Percutaneous Coronary Interventions in East Asian Populations

Because guidelines and recommendations in response to multiple randomized clinical trials (RCTs) of new therapies undergo rapid changes, antithrombotic therapies for patients after acute coronary syndrome, or percutaneous coronary intervention, are becoming more complex in daily clinical practice. The proportion of Asian populations enrolled in landmark RCTs is substantially low, which limits the direct application of trial findings into clinical practice in Asian countries. Moreover, compared with Caucasian patients, East Asian patients are considered to have a different ischemia/bleeding propensity in response to antithrombotic therapy, known as the "East Asian paradox" (ie, more bleeding events but fewer thromboembolic events). Coincident with consecutive RCTs in Western populations to optimize antithrombotic strategies, several such studies have now been conducted in East Asian cohorts. Herein, we provide a comprehensive summary of the key RCTs in this regard and propose future directions and perspectives for optimal antithrombotic therapies in East Asian patients.

Female sex as an independent predictor of high bleeding risk among East Asian percutaneous coronary intervention patients: A sex difference analysis

BACKGROUND

Sex differences in the outcomes following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) have been identified in Western countries. However, data on the long-term outcomes for bleeding events, particularly in East Asia where the aging population is growing rapidly and consists predominantly of women, remain scarce.

METHODS

We analyzed 2,494 ACS survivors from a multicenter PCI registry who underwent PCI between 2009 and 2012. The primary outcome was readmission for major bleeding at 2 years. Survival curves were generated with the cumulative incidence function. The adjusted hazard ratios were evaluated for the primary outcomes by sex using (1) Fine-Gray models and (2) Cox regression models.

RESULTS

There were 548 women (22.0%) in this cohort. The women were older (73.7 ± 10.8 years vs. 65.4 ± 11.8 years, p < 0.001), had a lower body mass index (23.0 ± 3.9 vs. 24.3 ± 3.6, p < 0.001), and had more comorbidities such as renal failure (49.4% vs. 36.3%, p < 0.001) and previous heart failure (8.4% vs. 4.5%, p < 0.001). Fewer women were discharged with statins (81.9% vs. 86.5%, p = 0.025) or beta blockers (70.6% vs. 77.1%, p = 0.007). During the 2-year follow-up, the unadjusted readmission rates for bleeding were higher among women (4.9% versus 2.4% at 2 years after discharge). Multivariable competing risk analysis with the Fine-Gray model and Cox regression model further demonstrated that female sex was associated with a higher risk of bleeding.

CONCLUSIONS

Among patients treated with PCI, women had a higher incidence of bleeding events requiring readmission. Sex disparities in the etiologies of readmission following PCI suggest the need for targeted treatment strategies. A strict follow-up after discharge could be beneficial for women to further reduce their risk.

Percutaneous Treatment of Unprotected Left Main Disease With Thin-Strut Durable-Polymer or Early Generation Thicker-Strutted and Coated Bioabsorbable-Polymer Drug-Eluting Stents in a Large-Scale Registry

BACKGROUND

The ideal drug-eluting stent (DES) for the treatment of unprotected left main coronary artery (ULMCA) is unknown. We compared percutaneous coronary intervention (PCI) using durable polymers versus early-generation, thicker strutted and coated bioabsorbable polymers for ULMCA disease.

METHODS

Patients who underwent ULMCA PCI (893 patients) from April 2008 to November 2014 were identified from the Grand-DES registry. The primary end point was 3-year target lesion failure (TLF) after propensity score matching.

RESULTS

The final analysis included 754 patients (84.4%) and 139 patients (15.6%) in the durable and bioabsorbable polymer group, respectively. The groups differed significantly in lesion and procedural characteristics. Propensity score-matched analysis revealed a trend toward a lower 3-year TLF in the durable polymer group (log rank p=0.071). Independent predictors of 3-year TLF were chronic kidney disease, presentation with acute myocardial infarction, and a two-stenting technique for ULMCA lesions. Definite/probable stent thrombosis rates at 3-years were low in both groups (0.8% vs. 0.7%, p=0.925).

CONCLUSIONS

The safety of ULCMA PCI was excellent, and durable and bioabsorbable polymer DES provided similar clinical outcomes at 3-year follow-up. Landmark analysis revealed that the durable polymer group had a lower TLF rate from 9 months. Further studies are needed to confirm these results.

Sarcopenia Index as a Predictor of Clinical Outcomes in Older Patients with Coronary Artery Disease

To demonstrate the association of the serum creatinine/serum cystatin C ratio (sarcopenia index, SI) with clinical outcomes including cardiovascular and bleeding risk in older patients who underwent percutaneous coronary intervention (PCI), we analyzed a multicenter nation-wide pooled registry. A total of 1086 older patients (65 years or older) who underwent PCI with second-generation drug-eluting stents (DES) were enrolled. The total population was divided into quartiles according to the SI, stratified by sex. The primary clinical outcomes were major adverse cardiovascular events (MACE, all-cause death, myocardial infarction and target lesion revascularization) and thrombolysis in myocardial infarction major and minor bleeding during a 3-year follow-up period. In the total population, MACE occurred within 3 years in 154 (14.2%) patients. The lowest SI quartile group (Q1) had a significantly higher 3-year MACE rate (Q1 vs. Q2-4; 23.1% vs. 11.2%, p < 0.001), while bleeding event rates were similar between the groups (Q1 vs. Q2-4; 2.6% vs. 2.2%, p = 0.656). The Cox proportional hazard model showed that lower SI is an independent predictor for MACE events (HR 2.23, 95% CI 1.62-3.07, p < 0.001). The SI, a surrogate for the degree of muscle mass, is associated with cardiovascular and non-cardiovascular death, but not with bleeding in older patients who underwent PCI.

Ethnic Differences in Oral Antithrombotic Therapy

Oral antithrombotic therapy (antiplatelet therapy and anticoagulation therapy) is a key element of pharmacotherapy in patients with cardiovascular (CV) disease. Several reports of ethnic differences have suggested that there may be difference therapeutic requirements and response to therapy for antithrombotic therapy. In particular for East Asians, there seems to be a lower incidence of ischemic outcomes and a higher incidence of bleeding outcomes compared to Westerners. The purpose of this review is to describe the ethnicity-related differences in antithrombotic therapy for CV disease and to discuss the need to establish a more effective and targeted antithrombotic treatment strategy in East Asians.

Antithrombotic Strategy for Patients with Acute Coronary Syndrome: A Perspective from East Asia

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention has become the standard of care, particularly in patients with acute coronary syndrome (ACS). Current clinical guidelines recommend novel P2Y12 inhibitors (e.g., prasugrel or ticagrelor) in addition to aspirin based on the results of representative randomized controlled trials conducted predominantly in Western countries. These agents were superior to clopidogrel in reducing the composite ischemic events, with a trade-off of the increased bleeding events. However, multiple differences exist between East Asian and Western patients, especially with respect to their physique, thrombogenicity, hemorrhagic diathesis, and on-treatment platelet reactivity. Recent studies from East Asian countries (e.g., Japan or South Korea) have consistently demonstrated that use of novel P2Y12 inhibitors is associated with a higher risk of bleeding events than use of clopidogrel, despite borderline statistical difference in the incidence of composite ischemic events. Additionally, multiple studies have shown that the optimal duration of DAPT may be shorter in East Asian than Western patients. This review summarizes clinical studies of antithrombotic strategies in East Asian patients with ACS. Understanding these differences in antithrombotic strategies including DAPT and their impacts on clinical outcomes will aid in selection of the optimal tailored antithrombotic therapy for patients with ACS.

Efficacy and Safety of Long-Term and Short-Term Dual Antiplatelet Therapy: A Meta-Analysis of Comparison between Asians and Non-Asians

While dual antiplatelet therapy (DAPT) is essential after percutaneous coronary intervention (PCI), the optimal duration is affected by various factors. However, the effect of ethnicity on DAPT duration has not been fully evaluated. In this study, we evaluated the different effect of DAPT duration by ethnicity. We searched Pubmed, Embase, Cochrane library, and relevant websites to search for randomized clinical trials (RCT) assessing the clinical impact of long term DAPT (L-DAPT) and short term DAPT (S-DAPT). Studies were divided by ethnicity, and we compared the efficacy and safety of DAPT duration in each ethnic group. Thirteen RCTs including 38,255 patients (five East Asian studies and eight non–East Asian studies) were eligible for analysis. For the primary outcome, L-DAPT showed a significantly lower rate of primary outcome only in non–East Asians (S-DAPT vs. L-DAPT, odds ratio (OR) = 1.16, 95% confidence interval (CI): 1.02–1.32, p = 0.02), while in East Asians, the effect of S-DAPT and L-DAPT were comparable. S-DAPT significantly increased ischemic events only in non–East Asians (S-DAPT vs. L-DAPT, OR = 1.24, 95% CI: 1.09–1.42, p <0.01), while bleeding events were decreased by S-DAPT in both ethnicities. These results demonstrate that the adequate DAPT duration after PCI may be different in East Asians.