Sex-Based Differences in Bleeding Risk After Percutaneous Coronary Intervention and Implications for the Academic Research Consortium High Bleeding Risk Criteria

Consecutive or selectively included high bleeding risk patients in the MASTER DAPT screening log and trial

AIMS

Screening logs have the potential to appraise the actual prevalence and distribution of predefined patient subsets, avoiding selection biases, which are inevitably and potentially present in randomised trials and real-world registries, respectively. We aimed to assess the prevalence of high bleeding risk (HBR) characteristics in the real world and the external validity of the MASTER DAPT trial.

METHODS AND RESULTS

All consecutive patients who underwent percutaneous coronary intervention (PCI) for at least two consecutive weeks across 65 sites participating in the trial were entered into a screening log. Of 2,847 consecutive patients, 1,098 (38.6 %) were HBR and 109 (9.9 %) consented for trial participation. PRECISE-DAPT score ≥ 25 was the most frequent HBR feature, followed by advanced age, use of oral anticoagulation (OAC) and anaemia. Compared with consecutive HBR patients, consenting patients were older (≥ 75 years: 69 % versus 62 %, absolute standardized difference [SD] 0.16), more frequently male (78 % versus 71 %, absolute SD 0.18), had higher use of OAC (38 % versus 20 %, absolute SD 0.39), treatment with steroids or nonsteroidal anti-inflammatory drugs (10 % versus 5 %, SD 0.16), and prior cerebrovascular events (10 % versus 6 %, absolute SD 0.18) but lower PRECISE DAPT score ≥ 25 (54 % versus 66 %, absolute SD 0.24).

CONCLUSIONS

The HBR criteria distribution differed between consecutive versus selectively included HBR patients, suggesting the existence of selection biases in the trial population.

Sex Differences in Bleeding Risk Associated With Antithrombotic Therapy Following Percutaneous Coronary Intervention

Background: Antithrombotic therapy is crucial for secondary prevention of cardiovascular disease (CVD), but women with CVD may face increased bleeding complications post-percutaneous coronary intervention (PCI) under antithrombotic therapy. However, women are often underrepresented in clinical trials in this field, so evidence for sex-specific recommendations is lacking. Methods and Results: A search on PubMed was conducted for English-language articles addressing bleeding complications and antithrombotic therapy in women. Despite women potentially showing higher baseline platelet responsiveness than men, the clinical implications remain unclear. Concerning antiplatelet therapy post-PCI, although women have an elevated bleeding risk in the acute phase, no sex differences were observed in the chronic phase. However, women require specific considerations for factors such as age, renal function, and weight when determining the dose and duration of antiplatelet therapy. Regarding anticoagulation post-PCI, direct oral anticoagulants may pose a lower bleeding risk in women compared with warfarin. Concerning triple antithrombotic therapy (TAT) post-PCI for patients with atrial fibrillation, there is a lack of evidence on whether sex differences should be considered in the duration and regimen of TAT. Conclusions: Recent findings on sex differences in post-PCI bleeding complications did not provide enough evidence to recommend specific therapies for women. Further studies are needed to address this gap and recommend optimal antithrombotic therapy post-PCI for women.

Antithrombotic therapy in patients with acute coronary syndrome: similarities and differences between a European expert consensus document and the 2023 European Society of Cardiology guidelines

Antithrombotic therapy represents the cornerstone of the pharmacological treatment in patients with acute coronary syndrome (ACS). The optimal combination and duration of antithrombotic therapy is still matter of debate requiring a critical assessment of patient comorbidities, clinical presentation, revascularization modality, and/or optimization of medical treatment. The 2023 European Society of Cardiology (ESC) guidelines for the management of patients with ACS encompassing both patients with and without ST segment elevation ACS have been recently published. Shortly before, a European expert consensus task force produced guidance for clinicians on the management of antithrombotic therapy in patients with ACS as well as chronic coronary syndrome. The scope of this manuscript is to provide a critical appraisal of differences and similarities between the European consensus paper and the latest ESC recommendations on oral antithrombotic regimens in ACS patients.

Abbreviated or Standard Dual Antiplatelet Therapy by Sex in Patients at High Bleeding Risk: A Prespecified Secondary Analysis of a Randomized Clinical Trial

Importance

Abbreviated dual antiplatelet therapy (DAPT) reduces bleeding with no increase in ischemic events in patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI).

Objectives

To evaluate the association of sex with the comparative effectiveness of abbreviated vs standard DAPT in patients with HBR.

Design, Setting, and Patients

This prespecified subgroup comparative effectiveness analysis followed the Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated vs Standard DAPT Regimen (MASTER DAPT) trial, a multicenter, randomized, open-label clinical trial conducted at 140 sites in 30 countries and performed from February 28, 2017, to December 5, 2019. A total of 4579 patients with HBR were randomized at 1 month after PCI to abbreviated or standard DAPT. Data were analyzed from July 1 to October 31, 2022.

Interventions

Abbreviated (immediate DAPT discontinuation, followed by single APT for ≥6 months) or standard (DAPT for ≥2 additional months, followed by single APT for 11 months) treatment groups.

Main Outcomes and Measures

One-year net adverse clinical events (NACEs) (a composite of death due to any cause, myocardial infarction, stroke, or major bleeding), major adverse cardiac or cerebral events (MACCEs) (a composite of death due to any cause, myocardial infarction, or stroke), and major or clinically relevant nonmajor bleeding (MCB).

Results

Of the 4579 patients included in the analysis, 1408 (30.7%) were women and 3171 (69.3%) were men (mean [SD] age, 76.0 [8.7] years). Ischemic and bleeding events were similar between sexes. Abbreviated DAPT was associated with comparable NACE rates in men (hazard ratio [HR], 0.97 [95% CI, 0.75-1.24]) and women (HR, 0.87 [95% CI, 0.60-1.26]; P = .65 for interaction). There was evidence of heterogeneity of treatment effect by sex for MACCEs, with a trend toward benefit in women (HR, 0.68 [95% CI, 0.44-1.05]) but not in men (HR, 1.17 [95% CI, 0.88-1.55]; P = .04 for interaction). There was no significant interaction for MCB across sex, although the benefit with abbreviated DAPT was relatively greater in men (HR, 0.65 [95% CI, 0.50-0.84]) than in women (HR, 0.77 [95% CI, 0.53-1.12]; P = .46 for interaction). Results remained consistent in patients with acute coronary syndrome and/or complex PCI.

Conclusions and Relevance

These findings suggest that women with HBR did not experience higher rates of ischemic or bleeding events compared with men and may derive particular benefit from abbreviated compared with standard DAPT owing to these numerically lower rates of events.

Trial Registration

ClinicalTrials.gov Identifier: NCT03023020.

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.

Antithrombotic Therapy Optimization in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

The antithrombotic management of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) poses numerous challenges. Triple antithrombotic therapy (TAT), which combines dual antiplatelet therapy (DAPT) with oral anticoagulation (OAC), provides anti-ischemic protection but increases the risk of bleeding. Therefore, TAT is generally limited to a short phase (1 week) after PCI, followed by aspirin withdrawal and continuation of 6-12 months of dual antithrombotic therapy (DAT), comprising OAC plus clopidogrel, followed by OAC alone. This pharmacological approach has been shown to mitigate bleeding risk while preserving adequate anti-ischemic efficacy. However, the decision-making process remains complex in elderly patients and those with co-morbidities, significantly influencing ischemic and bleeding risk. In this review, we discuss the available evidence in this area from randomized clinical trials and meta-analyses for post-procedural antithrombotic therapies in patients with non-valvular AF undergoing PCI.

Sex-Based Outcomes of P2Y12 Inhibitor Monotherapy After Three Months of Dual Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

In patients undergoing percutaneous coronary intervention (PCI) in the SMART-CHOICE trial, P2Y12 inhibitor monotherapy after three months of dual antiplatelet therapy (DAPT) achieved clinical outcomes comparable to those of 12 months of DAPT. Nonetheless, the effects of sex on these outcomes remain unknown.

METHODS

This open-label, non-inferiority, randomized study, conducted in 33 hospitals in South Korea, included 2,993 patients undergoing PCI with drug-eluting stents. Patients were randomly assigned to receive DAPT (aspirin plus a P2Y12 inhibitor) for three months then P2Y12 inhibitor alone for nine months, or DAPT for the entire 12 months. The primary endpoints were major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) 12 months after the index procedure. The bleeding endpoints were Bleeding Academic Research Consortium (BARC) bleeding types 2 to 5.

RESULTS

Of the patients, 795 (26.6%) were women, who were older and had a higher prevalence of hypertension, diabetes, and dyslipidemia than men. The sexes exhibited comparable primary endpoints (adjusted hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.55-1.55; P = 0.770) and bleeding endpoints (adjusted HR, 1.07; 95% CI, 0.63-1.81; P = 0.811). P2Y12 inhibitor monotherapy vs DAPT was associated with lower risk of BARC type 2 to 5 bleeding in women (adjusted HR, 0.40; 95% CI, 0.16-0.98; P = 0.045) but the difference was not statistically significant when using the Bonferroni correction. The primary endpoints were similar between treatment groups in both sexes.

CONCLUSION

In both sexes undergoing PCI, P2Y12 inhibitor monotherapy after three months of DAPT achieved similar risks of the primary endpoints and the bleeding events compared with prolonged DAPT. Therefore, the benefits of early aspirin withdrawal with ongoing P2Y12 inhibitors may be comparable in women and men.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02079194.

Sex differences in the management of atherosclerotic cardiovascular disease

Disparities between women and men persist in the diagnosis, treatment, and prognosis of atherosclerotic cardiovascular disease (ASCVD). Despite growing attention to sex-based differences in cardiovascular care, there are continued disparities in short- and long-term outcomes. Such disparities highlight the need to identify pathophysiologic differences in treatment patterns for stable ischemic heart disease, non-ST elevation myocardial infarction (NSTE-ACS), ST-elevation myocardial infarction (STEMI), and myocardial infarction with non-obstructive coronary arteries (MINOCA). The role of age as an effect modifier should also be considered given that young women diagnosed with ACS continue to experience increased rates of in-hospital mortality and major adverse cardiovascular events. Both patient-directed and systems-based approaches remain integral to improve outcomes in cardiovascular care. While inadequate representation of women in clinical trials remains a barrier to the implementation of evidence-based therapies, a growing body of data has established the efficacy and safety of medications in women across acute coronary syndromes. This review seeks to feature existing data on the differential treatment guidelines, care implementation, and cardiovascular outcomes between women and men, highlighting next directions for clinical investigation.

Fatal, ischemic and bleeding risk of patients meeting the selection criteria of the TWILIGHT trial: Insights from a large PCI registry

BACKGROUND

The TWILIGHT trial (NCT02270242) demonstrated that in selected high-risk patients undergoing percutaneous coronary intervention (PCI) ticagrelor monotherapy significantly reduced bleeding complications without ischemic harm as compared to ticagrelor plus aspirin after 3-month of dual antiplatelet therapy. The aim of this analysis was to assess the applicability of the findings TWILIGHT trial to a real-world population.

METHODS

Patients undergoing PCI at a tertiary center between 2012 and 2019 and not meeting any TWILIGHT exclusion criterion (oral anticoagulation treatment, ST-segment elevation myocardial infarction [MI], cardiogenic shock, dialysis, prior stroke, or thrombocytopenia) were included. Patients were stratified into 2 groups based on whether they fulfilled the TWILIGHT inclusion criteria (high-risk) or not (low-risk). The primary outcome was all-cause death; the key secondary outcomes were MI and major bleeding at 1 year after PCI.

RESULTS

Out of 13,136 included patients, 11,018 (83%) were at high risk. At 1-year, these patients had an approximately 3 folds greater hazard of death (1.4% vs 0.4%, HR 3.63, 95% CI 1.70-7.77) and MI (1.8% vs 0.6%, HR 2.81, 95% CI 1.56-5.04) and a nearly 2 folds higher risk of major bleeding (3.3% vs 1.8%, HR 1.86, 95% CI 1.32-2.62) as compared to low-risk patients.

CONCLUSION

Among patients not meeting the TWILIGHT exclusion criteria from a large PCI registry, the high-risk inclusion criteria of the TWILIGHT trial were met by the majority of patients and were associated with an increased risk of mortality and MI and a moderately elevated risk of bleeding.

Factors Associated with Increased Length of Stay in Post Primary Percutaneous Coronary Intervention Patients: A Scoping Review

Several studies identify factors affecting increased length of stay (LOS) in patients with post-primary percutaneous coronary intervention (PCI). However, there has not been a review study that synthesizes these results. This study aimed to describe the duration of LOS and factors associated with increased LOS among patients with STEMI after PPCI. This study used scoping review using EBSCO-host Academic Search Complete, PubMed, Scopus, Taylor & Francis, and Google Scholar databases. The keywords used in English were "adults OR middle-aged" AND "length of stay OR hospital stay" AND "primary percutaneous coronary intervention OR PPCI" AND "myocardial infarction OR coronary infarction OR cardiovascular disease". The inclusion criteria for articles were: the article was a full-text in English; the sample was STEMI patients who had undergone a PPCI procedure; and the article discussed the LOS. We found 13 articles discussing the duration and factors affecting LOS in patients post-PPCI. The duration of LOS was the fastest 48 hours, and the longest of LOS was 10.2 days. Factors influencing LOS are categorized into three predictors: low, moderate, and high. Post-procedure complications after PPCI was the most influential factors in increasing the LOS duration. Professional health workers, especially nurses, can identify various factors that can be modified to prevent complications and worsen disease prognosis to increase LOS efficiency.

Incidence, Predictors, and Outcomes of Major Bleeding Among Patients Hospitalized With Acute Heart Failure

Acute heart failure (AHF) is a common etiology of hospitalization and is associated with morbidity, including bleeding. In this study, the authors sought to assess the incidence, types, and associates of major bleeding in patients hospitalized with AHF. The National Inpatient Sample from October 2015 to December 2018 was used to identify patients with AHF. The incidence of common bleeding etiologies, and patient demographics, co-morbidities, associated acute cardiac diagnoses, and invasive procedures, were identified. The multivariable logistic regression was used to identify predictors of bleeding and the association of bleeding episodes with inpatient mortality. During the study period, 1,106,634 patients were admitted with a primary diagnosis of AHF, of whom 58,955 (5.3%) had an episode of bleeding. Common bleeding sources were gastrointestinal (25.7%), hematuria (24%), respiratory (23.6%), and procedure-related bleeding (2.5%). Major bleeding was more common in patients with AHF with preserved ejection fraction (odds ratio 1.14, confidence interval 1.12 to 1.16, p <0.001) versus AHF with reduced ejection fraction and in men (odds ratio 1.3, confidence interval 1.29 to 1.31, p <0.001). Major bleeding was associated with higher mortality (7.0% vs 2.4%, p <0.001), longer length of stay (7 vs 4 days, p <0.001), and higher inpatient costs ($49,658 vs $27,636, p <0.001). In conclusion, major bleeding occurs in 5.3% of patients hospitalized with AHF and is associated with higher inpatient mortality and costs and longer length of stay.

Sex Differences in Acute Coronary Syndromes: A Global Perspective

Despite increasing evidence and improvements in the care of acute coronary syndromes (ACS), sex disparities in presentation, comorbidities, access to care and invasive therapies remain, even in the most developed countries. Much of the currently available data are derived from more developed regions of the world, particularly Europe and the Americas. In contrast, in more resource-constrained settings, especially in Sub-Saharan Africa and some parts of Asia, more data are needed to identify the prevalence of sex disparities in ACS, as well as factors responsible for these disparities, particularly cultural, socioeconomic, educational and psychosocial. This review summarizes the available evidence of sex differences in ACS, including risk factors, pathophysiology and biases in care from a global perspective, with a focus on each of the six different World Health Organization (WHO) regions of the world. Regional trends and disparities, gaps in evidence and solutions to mitigate these disparities are also discussed.

Risk Scores of Bleeding Complications in Patients on Dual Antiplatelet Therapy: How to Optimize Identification of Patients at Risk of Bleeding after Percutaneous Coronary Intervention

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor in patients undergoing percutaneous coronary intervention (PCI) reduces the risk of ischemic events but reduces the risk of ischemic events but increases the risk of bleeding, which in turn is associated with increased morbidity and mortality. With the aim to offer personalized treatment regimens to patients undergoing PCI, much effort has been devoted in the last decade to improve the identification of patients at increased risk of bleeding complications. Several clinical scores have been developed and validated in large populations of patients with coronary artery disease (CAD) and are currently recommended by guidelines to evaluate bleeding risk and individualize the type and duration of antithrombotic therapy after PCI. In clinical practice, these risk scores are conventionally computed at the time of PCI using baseline features and risk factors. Yet, bleeding risk is dynamic and can change over time after PCI, since patients can worsen or improve their clinical status and accumulate comorbidities. Indeed, evidence now exists that the estimated risk of bleeding after PCI can change over time. This concept is relevant, as the inappropriate estimation of bleeding risk, either at the time of revascularization or subsequent follow-up visits, might lead to erroneous therapeutic management. Serial evaluation and recalculation of bleeding risk scores during follow-up can be important in clinical practice to improve the identification of patients at higher risk of bleeding while on DAPT after PCI.

Perioperative coronary artery spasm after off-pump coronary artery bypass grafting in the non-manipulated coronary artery

BACKGROUND

Perioperative coronary artery spasm (CAS) following coronary artery bypass grafting (CABG) is a severe or lethal condition that is rarely reported. In addition, rare cases with CAS following CABG in the non-manipulated coronary artery are angiographically documented in the perioperative period. We aimed to report our experiences on the diagnosis and treatment of a case with CAS following off-pump CABG in the non-manipulated coronary artery.

METHODS

A 57-year old male with coronary heart disease and unstable angina willing to undergo CABG was admitted to our department. CABG was recommended as he showed 90% stenosis in distal left anterior descending artery, 90% stenosis in intermediate branch, 90% stenosis in left circumflex coronary artery, as well as 50% stenosis in proximal right coronary artery (RCA).

RESULTS

After CABG, the patient showed Adams-Stokes syndrome and ST-segment elevation. Then CPR was conducted and coronary angiography indicated perioperative CAS in the non-manipulated posterior descending artery. For the treatment, the patient received nitroglycerin injection into the coronary artery by catheter and pumping of diltiazem. Finally, the patient was discharged on day 7 after surgery. A comprehensive literature search was conducted to summarize the studies focused on the diagnosis and treatment of such condition, which indicated that all of the CAS cases occurred in the manipulated vessels, except one study showing CAS in the untouched native coronary artery which was similar with our case.

CONCLUSIONS

Perioperative CAS in the non-manipulated coronary artery following CABG is a severe or lethal condition that is rarely reported, which deserves close attention by the clinicians in clinical practice.

ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes

PURPOSE

Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men.

RECENT FINDINGS

This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.

Ticagrelor Monotherapy or Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation: Per-Protocol Analysis of the GLOBAL LEADERS Trial

Background

In the GLOBAL LEADERS trial, ticagrelor monotherapy beyond 1 month compared with standard antiplatelet regimens after coronary stent implantation did not improve outcomes at intention‐to‐treat analysis. Considerable differences in treatment adherence between the experimental and control groups may have affected the intention‐to‐treat results. In this reanalysis of the GLOBAL LEADERS trial, we compared the experimental and control treatment strategies in a per‐protocol analysis of patients who did not deviate from the study protocol.

Methods and Results

Baseline and postrandomization information were used to classify whether and when patients were deviating from the study protocol. With logistic regressions, we derived time‐varying inverse probabilities of nondeviation from protocol to reconstruct the trial population without protocol deviation. The primary end point was a composite of all‐cause mortality or nonfatal Q‐wave myocardial infarction at 2 years. At 2‐year follow‐up, 1103 (13.8%) of 7980 patients in the experimental group and 785 (9.8%) of 7988 patients in the control group qualified as protocol deviators. At per‐protocol analysis, the rate ratio for the primary end point was 0.88 (95% CI, 0.75–1.03; P=0.10) on the basis of 274 versus 325 events in the experimental versus control group. The rate ratio for the key safety end point of major bleeding was 1.00 (95% CI, 0.79–1.26; P=0.99). The per‐protocol and intention‐to‐treat effect estimates were overall consistent.

Conclusions

Among patients who complied with the study protocol in the GLOBAL LEADERS trial, ticagrelor plus aspirin for 1 month followed by ticagrelor monotherapy was not superior to 1‐year standard dual antiplatelet therapy followed by aspirin alone at 2 years after coronary stenting.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01813435.

Update on Management of Cardiovascular Diseases in Women

Cardiovascular diseases (CVD) have a lower prevalence in women than men; although, a higher mortality rate and a poorer prognosis are more common in women. However, there is a misperception of CVD female risk since women have commonly been considered more protected so that the real threat is vastly underestimated. Consequently, female patients are more likely to be treated less aggressively, and a lower rate of diagnostic and interventional procedures is performed in women than in men. In addition, there are substantial sex differences in CVD, so different strategies are needed. This review aims to evaluate the main gender-specific approaches in CVD.

Thrombotic vs. Bleeding Events of Interruption of Dual Antiplatelet Therapy within 12 Months among Patients with Stent-Driven High Ischemic Risk Definition following PCI

Background. There is a paucity of real-world data regarding the clinical impact of dual antiplatelet therapy (DAPT) interruption (temporary or permanent) among patients at high ischemic risk. The aim of this study was to assess the risk of cardiovascular events after interruption of DAPT in high-risk PCI population. Methods. This study used data from the Fuwai PCI registry, a large, prospective cohort of consecutive patients who underwent PCI. We assessed 3,931 patients with at least 1 high ischemic risk criteria of stent-related recurrent ischemic events proposed in the 2017 ESC guidelines for focused update on DAPT who were free of major cardiac events in the first 12 months. The primary ischemic endpoint was 30-month major adverse cardiac and cerebrovascular events, and the key safety endpoints were BARC class 2, 3, or 5 bleeding and net adverse clinical events. Results. DAPT interruption within 12 months occurred in 1,122 patients (28.5%), most of which were due to bleeding events or patients’ noncompliance to treatment. A multivariate Cox regression model, propensity score (PS) matching, and inverse probability of treatment weighting (IPTW) based on the propensity score demonstrated that DAPT interruption significantly increased the risk of primary ischemic endpoint compared with prolonged DAPT (3.9% vs. 2.2%; Cox-adjusted hazard ratio (HR): 1.840; 95% confidence interval (CI): 1.247 to 2.716; PS matching-HR: 2.049 [1.236–3.399]; IPTW-adjusted HR: 1.843 [1.250–2.717]). This difference was driven mainly by all-cause death (1.8% vs. 0.7%) and MI (1.3% vs. 0.5%). Furthermore, the rate of net adverse clinical events (4.9% vs. 3.2%; Cox-adjusted HR: 1.581 [1.128–2.216]; PS matching-HR: 1.639 [1.075–2.499]; IPTW-adjusted HR: 1.554 [1.110–2.177]) was also higher in patients with DAPT interruption (≤12 months), whereas no significant differences between groups were observed in terms of BARC 2, 3, or 5 bleeding. These findings were consistent across various stent-driven high-ischemic risk subsets with respect to the primary ischemic endpoints, with a greater magnitude of harm among patients with diffuse multivessel diabetic coronary artery disease. Conclusions. In patients undergoing high-risk PCI, interruption of DAPT in the first 12 months occurred infrequently and was associated with a significantly higher adjusted risk of major adverse cardiovascular events and net adverse clinical events. 2017 ESC stent-driven high ischemic risk criteria may help clinicians to discriminate patient selection in the use of long-term DAPT when the ischemic risk certainly overcomes the bleeding one.

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

Background

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

Methods

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

Results

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

Conclusion

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

Determinants of Functional Improvement After Cardiac Rehabilitation in Acute Coronary Syndrome

Introduction

Cardiac rehabilitation (CR) is an effective tool for secondary prevention after acute coronary syndrome (ACS).

Aim

Aim of our study was to find the significant determinants of exercise capacity (evaluated with the six-minute walking test—6-MWT) and functional improvement in patients undergoing CR after an ACS.

Methods

The study group included 298 patients (mean age 61.6 ± 10.2 years; males 80.2%) who, after ACS, were enrolled in CR program at Niguarda Hospital in Milan from 2015 to 2018. For all patients, we collected anamnestic, clinical and instrumental cardiological data. All patients performed a 6-MWT at the beginning (6-MWT-1) and at the end (6-MWT-2) of CR program. Δ meters were used to represent functional improvement.

Results

Multiple linear regression models were carried out for 6-MWT-1, 6-MWT-2, Δ meters and % Δ meters. Standardized regression coefficients showed that age (β = − 0.237; p < 0.001), BMI (β = − 0.116; p = 0.006) and heart rate (β = − 0.082; p = 0.040) were determinants of exercise capacity (6MWT-1 and 2), whereas age (β = −.231; p = 0.004), sex (β = − 0.187; p = 0.008) and BMI (β = − 0.164; p = 0.022) were determinants of functional improvement (Δ meters).

Conclusions

Our data showed that functional improvement after CR in ACS patients is mainly related to non-cardiological variables. Instead it is related to intrinsic factors, both modifiable (BMI) and non-modifiable (age, sex).

Supplementary Information

The online version contains supplementary material available at 10.1007/s40292-021-00473-7.