Impact of prior history of cancer in the outcomes of patients with atrial fibrillation

Introduction

Atrial fibrillation (AF) is common among cancer survivors, but anticoagulant therapy in is particularly challenging in this population.

Aim

We analyzed how a previous diagnosis of cancer influences the embolic and hemorrhagic risk in AF patients in order to guide anticoagulant therapies.

Methods

We used a large retrospective and observational cohort of AF patients from Vigo, Spain (2014–2018). Primary endpoint were embolic and haemorrhagic events during follow-up. Secondary endpoints were all cause mortality, CV mortality, acute myocardial infarction (AMI) and heart failure (HF) admission.

Results

From the 16,056 included patients, 7.1% had a current/past diagnosis of cancer. Median follow-up was 4.9 years. The rate of anticoagulation therapy was similar in cancer and non-cancer patients (74.8% vs 75.8) although there was a higher prescription of heparin and a lower prescription of VKA in cancer group.

Cancer patients had a higher embolic (CHA2DS2-VASC 3.5±1.5 vs 3.2±1.5; p<.001) and hemorrhagic risk (HASBLED 3.0±1.2 vs 2.6±1.2; p<.001).

Embolic and hemorrhagic risk stratification with CHA2DS2-VASC and HASBLED scores was only accurate in patients with past (non-active) cancer (sHR CHA2DS2-VASC for embolic events: 1.26, 95% CI 1.02–1.54, P=.028 and sHR HASBLED for bleeding events 1.11, 95% CI 1.01–1.23, P=.029) but not in active-cancer patients (CHADS2-VASC sHR 1.14, 95% CI 0.98–1.32; p=.076 and HASBLED sHR 1.08, 95% CI 0.99–1.17; p=.070).

After adjusting by age, sex, CHA2DS2-VASC, HASBLED, and anticoagulation therapy, cancer was not associated with higher risk of embolic events (sHR 0.73, 95% CI 0.41–1.26; p=.256), neither in anticoagulated nor in non-anticoagulated patients. However, cancer patients presented a higher bleeding risk (sHR 1.18, 95% CI 1.07–1.30; p=0.001), both in anticoagulated and non-anticoagulated patients.

Anticoagulation therapy was associated with lower rate of embolic events and with higher rate of bleeding events in both groups of patients with and without cancer, although the embolic-hemorrhagic balance associated with anticoagulation was more favorable in cancer patients (for each avoided embolism with anticoagulation, 5.7 bleeding and 11.7 bleeding episodes occurred in cancer and non-cancer group respectively).

We found no association between cancer and AMI or CV mortality rates. All-cause mortality was higher in cancer patients. For HF, only chemotherapy-treated patients presented higher risk (sHR1.54, 95% CI 1.10–2.16; p=0.012).

Conclusion

Patients with prior history of cancer have higher bleeding risk but similar embolic risk compared to patients without cancer history. Anticoagulation significantly reduced embolic events, with an increase in bleeding outcomes. However, the embolic-hemorrhagic profile of anticoagulation was more favorable in patients with cancer than without it.

Funding Acknowledgement

Type of funding sources: None. Scores performances by cancer activityEmbolic/bleeding net clinical balance

Relation of contrast volume to new onset atrial fibrillation in acute coronary syndrome underwent percutaneous coronary intervention

Introduction

There is an important relationship between atrial fibrillation (AF) and contrast induced nephropathy (CIN). Several hypotheses were suggested to explain this unidirectional association between CIN and AF, like influence on renin-angiotensin-aldosterone system and the inflammatory pathway, as well as the use of iodinated contrasts -due to its possible interaction at the thyroid hormone regulation-.

Purpose

The aim of this study was to analyze the relation between contrast volume and the subsequent development of AF in patients with acute coronary syndrome (ACS)

Methods

A total of 6,133 ACS patients underwent PCI between 2010 and 2016 were analyzed. We have excluded 1,896 patients with prior history of AF, without data about contrast volume or with missing data about follow-up. The impact of contrast volume in the development of AF was assessed by Cox regression analysis. Hazard Ratios (HR) with 95% of confidence interval (CI) were reported. Maximum allowable contrast dose (MACD) was defined as 5*body weight/serum creatinine.

Results

From the total study population (4,237 patients, 64.3±12.8 years, 24.2% women), 399 (9.4%) developed AF during a mean follow-up of 3.5±2.4 years. Mean contrast volume used was 199.9±90.3 ml. Contrast volume was not associated with follow-up de novo AF (HR 0.99, 95% CI: 0.99–1.00; p=0.834). However, the ratio between contrast volume used and the maximum allowable contrast dose (CV/MACD) resulted a predictor of follow-up AF (HR 1.18, 95% CI: 1.02–1.37, p=0.027). The cumulative incidence of AF was 2.7 per 100 patients/year in patients with CV/MACD ≤1 and 4.8 per 100 patients/year in patients with CV/MACD >1. After adjusting for those variables associated with follow-up AF in the univariate analysis, the use of a contrast volume higher than MACD resulted an independent predictor of AF (HR 1.40, 95% CI: 1.03–1.89; p=0.032).

Conclusion

Doses of contrast volume higher than the maximum allowable contrast dose were independently associated with higher rates of AF during the follow-up.

Cumulative incidence of AF by groups

Funding Acknowledgement

Type of funding source: None

P880Cardiovascular mortality in patients with MINOCA and prognostic effect of statin treatment

Introduction

Several studies have showed a substantial risk of death in patients with MINOCA. However, little is still known about the causes of death in these patients compared to patients with MI with significant coronary lesions. On the other hand, using statins treatment in MINOCA has demonstrated to have prognosis benefit in a recent observational. In this study, we aim to describe the previous aspects in a contemporary cohort of patients with AMI.

Methods

We analyzed retrospective data from 4,499 consecutive patients discharged with a confirmed diagnosis of AMI from January/2010 to December/2016. Patients with coronary lesions <50% were classified as MINOCA. Patients with Tako-Tsubo syndrome were excluded. The time to death in patients with MINOCA vs MI-OCA was analyzed and the causes of death (CV death and non-CV death) were compared. When the cause of death was unknown, it was classified as unknown. The log-rank test was used to find differences in death rate between both groups. The effect of statin treatment was tested.

Results

643 patients (14.3%) were diagnosed with MINOCA. The prevalence of women was higher among patients with MINOCA (42.8% vs. 22.6%, p<0.01). The MINOCA were older (69±13 years vs. 66±13 years, p<0.01) with a higher prevalence of hypertension (70.85% vs. 65.3%, p=0.007), previous stroke (10.65 vs. 7.0%; p=0.001), COPD (14.0% vs. 9.95, p=0.002) and cancer history (9.2% vs. 7.6%, p=0.16). In contrast, the MINOCA patients had a lower prevalence of active smoking (19.9% vs. 35%, p<0.01), DM (33.0 vs. 29.4%, p=0.07), dyslipidemia (65.8% vs. 66.3%, p=0.81) and peripheral arteriography (7.3% vs. 8.3%, p=0.41). STEMI was the most frequent form of hospital presentation in the MINOCA cohort (41.95% vs. 19.1%). LVEF was higher in the MINOCA cohort (55% ± 11% vs. 52% ± 10%, p=0.006).

At discharge, 86.5% of MINOCAs were treated with statin vs. 86.5% in MI-OCA. The statins prescribed at discharge were of higher potency at 78.2% in MINOCA vs. 88.1% in MI-OCA, moderate potency in 16.1% vs 9.5%, and lower potency in 5.7% vs. 2.4%, respectively (p=0.001).

During a median follow-up of 15 months (IQR: 12.6–26.0 months), there were 383 deaths (8.5%), of which 314 occurred in the MI-OCA cohort (8.2%) and 69 occurred in MINOCA cohort (11.1%); p=0.001.

47.8% (n=33/69) were deaths of CV origin in the MINOCA group vs. 48.1% (n=151/314) in the MI-OCA group (p=0.61). The cause of death could not be determined in 6 patients (8.7%) with MINOCA and in 46 (14.7%) with MI-OCA (p=0.19).

No benefit of the statin treatment of any potency was observed in MINOCA (HR=0.8 [95% CI: 0.4–1.6]) whether there was benefit in MI-OCA group (HR=0.7 [95% CI 0.5–0.98]).

Conclusions

There is a considerable difference in the comorbidities between MINOCA and MI-OCA, but a similar rate of death of CV origin in the medium term. The lack of benefit of statin treatment has to be confirmed in other larger studies.

P3843Ischemic-bleeding balance according to history of prior bleeding in patients with acute coronary syndrome during treatment with dual antiplatelet therapy

Introduction

ESC guidelines recommend short-term dual antiplatelet therapy (DAPT) in patients with high bleeding risk. In this sense, patients with prior admissions by bleeding are considered of high-risk of bleeding. With our study, we aimed to show the ischemic-bleeding profile of patients with prior bleeding in comparison with those without prior bleeding during treatment with DAPT.

Methods

The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients with and without prior admission by bleeding. The impact of prior prior bleeding in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction, whereas for bleeding risk we have considered major bleeding defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal.

Results

From the 26,076 ACS patients, 1,105 have PAD (4.2%). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), 640 had myocardial infarction (2.5%) and 685 had major bleeding (2.6%). After propensity-score matching, we obtained two matched groups of 1,101 patients. In comparison with patients without prior bleeding, those with prior bleeding had higher risk of major bleeding (sHR 2.03, 95% CI 1.33–3.11, p=0.001) with similar risk of myocardial infarction (sHR 0.98, 95% CI 0.61–1.59, p=0.945), in comparison with those without PAD. The cumulative incidence of myocardial infarction was 31 and 32 per 1,000 patients/year in patients with and without prior bleeding, respectively. The cumulative incidence of major bleeding was 63 and 29 per 1,000 patients/year in patients with and without prior bleeding, respectively. The difference between myocardial infarction rate and major bleeding rate was −32 and +3 per 1,000 patient-years in patients with and without prior bleeding (Figure).

Conclusions

Patients with ACS and prior history of bleeding have a significant increment of bleeding risk during treatment with DAPT. In these patients, short-term DAPT (6 months) should be recommended.

P672Ischemic and bleeding risk after an acute coronary syndrome in patients with prior history of cancer treated with dual antiplatelet therapy

Introduction

Very few patients with history of cancer are included in clinical trials. With this study from real-life patients, we try to analyze the ischemic and bleeding risk of patients with history of cancer who were treated with dual antiplatelet therapy (DAPT) after an acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

Methods

The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients with and without previous history of recent cancer. The impact of prior cancer in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction (AMI), whereas for bleeding risk we have considered major bleeding (MB) defined as bleeding requiring hospital admission. All events occurred with DAPT, as follow-up time was censored by DAPT suspension/withdrawal.

Results

From the 26,076 ACS patients, 1,661 have prior history of cancer (6.4%). Patients with cancer were older, and with more cardiovascular risk factors. DAPT with prasugrel/ticagrelor was less frequently prescribed in patients with cancer in comparison with the rest of the population (14.5% vs 22.4%, p<0.001). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), and 640 AMI (2.5%) and 685 MB (2.6%) were reported. The unadjusted cumulative incidences of AMI and MB were higher in patients with prior cancer (5.1 and 5.2 per 100 patients/year, respectively) than in those with prior cancer (2.4 and 2.6 per 100 patients/year, respectively). After propensity-score matching, we obtained two matched groups of 1,656 patients. Patients with prior cancer showed a significant higher risk of AMI (sHR 1.44, 95% CI 1.01–2.04, p=0.044), but not higher risk of MB (sHR 1.21, 95% CI 0.88–1.68, p=0.248), in comparison with those without prior cancer.

Conclusions

In ACS patients discharged with DAPT after PCI, prior history of cancer is an independent factor of higher ischemic risk – in terms of AMI, but it is not an independent predictor of increased hemorrhagic risk.

P1558Clinical utility of the PRECISE-DAPT score in the prediction of hemorrhagic events in elderly patients with acute coronary syndrome

Introduction

The clinical utility and validity of the PRECISE-DAPT bleeding risk score for elderly patients with acute coronary syndrome (ACS) is unknown. We investigated the previous aspect in a contemporary population treated with percutaneous coronary intervention (PCI) and dual antiplatelet therapy (DAPT) at discharge.

Methods

Retrospectively, from 2010 to 2016, we studied 3,814 consecutive patients with the diagnosis of ACS. All patients were treated with in-hospital PCI and DAPT at discharge. Elderly was defined if patients aged ≥75 years. Patients were categorized into three risk strata according to their PRECISE-DAPT score (very low-low: <17 points, moderate: 18–24 points, and high risk: ≥25 points). We included the first bleeding event occurred during the first year after discharge. Bleeding events were defined according to the BARC classification system, and divided into two subgroups: BARC 2–5 and BARC 3–5. The ability to separate high bleeding risk patients from lower bleeding risk patients was checked by the cumulative incidence function curves and compared using the Fine-Gray test, thus adjusting for death (non-bleeding related) as a competing risk. Discrimination (C statistic) and calibration (Hosmer-Lemeshow test) were used to test the predictive capacity of the score in pts aged ≥75 years and <75 years.

Results

25.2% (n=961/3814) were ≥75 years old, 38.4% of them were women. DAPT duration was 11.5 (interquartile range [IQR] 2.5–13.7) vs. 12.0 (RIQ 8.2–14.1) months in the elderly vs. younger; (p<0.001). 92.5% (n=889) of the elderly were at high risk of bleeding (PRECISE-DAPT≥25 points), compared to 21.3% (n=607) of the youngest.

The incidence of BARC 2–5 and BARC 3–5 was 7.4% and 2.7% in the elderly compared to 5.1% and 1.4% among the younger patients (p<0.001). The figure shows the ability of the PRECISE-DAPT score at capturing the risk of BARC 2–5 bleeding (panel A and B), in both age groups.

Using the cut-off point ≥25, the effect in the prediction of BARC 2–5 bleeding and BARC 3–5 did not differ significantly between the elderly and those <75 years: sHR = 1.9 (95% CI: 1.2–6.00) in the elderly vs. 1.8 (95% CI: 1.3–2.5) in the other group (p=0.99) and sHR = 3.3 (95% CI: 1.9–6.0) vs. 3.6 (95% CI: 1.9–6.7) (p=0.83), respectively. There were no significant differences between the elderly and those under 75 years in terms of statistical C values either for BARC 2–5 bleeding (0.60 vs. 0.58) or BARC 3–5 bleeding (0.64 vs. 0.67). The score performed well in term of calibration in both groups (all p-values >0.3).

Conclusion

Although the use of PRECISE-DAPT resulted in classifying the majority of elderly patients at high risk of bleeding and despite exhibiting modest discriminative power, it performed well at classifying patients according to their risk of 1-year out-of-hospital bleeding in both age groups. PRECISE-DAPT appears to identify the truly low risk patients among the elderly, as compared to the younger group.

P677Association between bleeding after acute coronary syndrome and newly diagnosed cancers

Introduction

There is a growing body of evidence on the incidence and negative prognostic impact of post-discharge hemorrhagic complications after acute coronary syndrome (ACS). The aim of this study was to assess the association of post-discharge bleeding with new cancer diagnosis after ACS.

Methods

Data from a single-center registry of 3,644 ACS patients discharged with dual antiplatelet therapy (DAPT) were used to investigate the association between post-discharge bleeding and diagnosis of cancer. The adjusted effect of bleeding as time-varying covariate on subsequent cancer diagnosis was assessed using Cox regression models. Positive predictive values (PPVs) of bleeding for cancer diagnosis were calculated.

Results

During a median follow-up of 56.2 months, bleeding events were documented in 1,215 patients and new cancers in 227 patients. After multivariable adjustment, post-discharge bleeding was associated with cancer diagnosis (adjusted HR 3.43, 95% CI 2.62–4.50), but only spontaneous bleeding (adjusted HR=4.38, 95% CI 3.31–5.79). This association was stronger as the severity of the bleeding increased (HR= 1.52, 4.88, 7.30, and 12.29, for BARC type 1, 2, 3a, and 3b bleeding, respectively). With respect to the specific location of bleeding for diagnosis of cancer, only gastrointestinal, genitourinary and bronchopulmonary bleeding result strongly associated with site-specific cancers [Table]. No differences in the adjusted risk of cancer were found for those post-discharge bleedings that happened on-DAPT versus off-DAPT (HR for on-DAPT bleeding vs off-DAPT bleeding: 1.05, 95% CI 0.69–1.62; p=0.832). PPV for cancer diagnosis of post-discharge bleeding was 7.7%. (21.9% for genitourinary bleeding, 18.6% for bronchopulmonary bleeding, 5.8% for gastrointestinal bleeding, and 2.3% for other bleedings). Median time from bleeding to cancer was 4.6 months.

Variables HR 95% CI P Any bleeding 3.43 2.62–4.50 <0.001 Bleeding severity BARC 1 (n=622) 1.52 0.96–2.43 0.074 BARC 2 (n=436) 4.88 3.48–6.85 <0.001 BARC 3A (n=71) 7.30 3.68–14.46 <0.001 BARC 3B (n=46) 12.29 5.59–26.98 <0.001 BARC 3C (n=37) 3.07 0.73–12.84 0.125 Bleeding spontaneity Spontaneous (n=827) 4.38 3.31–5.79 <0.001 Traumatic bleeding (n=389) 1.29 0.69–2.41 0.418 Bleeding location Gastrointestinal (GI; n=327) 3.78 2.51–5.71 <0.001 Genitourinary (GU; n=228) 8.63 5.91–12.59 <0.001 Bronchopulmonary (BP; n=56) 4.26 1.85–9.84 0.001 Others (No GI, no GU, no BP; n=605) 1.32 0.81–2.18 0.264 Bleending with DAPT Bleeding ON-DAPT 3.50 2.56–4.80 <0.001 Bleeding OF-DAPT 3.34 2.29–4.89 <0.001

Conclusions

Spontaneous post-discharge bleeding in ACS patients is strongly associated with subsequent cancer diagnosis within the first 6 months. A prompt evaluation of bleeding could be useful for enabling an early detection of cancer in these patients.

P2539Impact of sex (female vs male) in the ischemic-bleeding profile after hospital discharge for acute coronary syndrome during treatment with dual antiplatelet therapy

Introduction

Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. These differences could condition the treatment and prognosis of women compared to men with Acute Coronary Syndrome (ACS). The aim of our study was to determine, after matching the baseline characteristics of patients according to gender, the prognosis of women versus men during treatment with Dual Antiplatelet Therapy (DAPT), after an ACS undergoing Percutaneous Coronary Intervention (PCI).

Methods

The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients according to gender (female vs male). The impact of gender in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction, whereas for bleeding risk we have considered major bleeding defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal.

Results

From the 26,076 ACS patients, 6,091 were women PAD (23.4%). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), 640 had myocardial infarction (2.5%) and 685 had major bleeding (2.6%). After propensity-score matching, we obtained two matched groups (according gender) of 5,341 patients. In comparison with male, female had similar risk of myocardial infarction (sHR 1.14, 95% CI 0.91–1.44, p=0.001) with lower risk of major bleeding (sHR 0.75, 95% CI 0.61–0.92, p=0.006). The cumulative incidence of myocardial infarction was 26 and 30 per 1,000 patients/year in men and women, respectively, during DAPT. And the cumulative incidence of major bleeding was 43 and 32 per 1,000 patients/year in men and women, respectively. The difference between myocardial infarction rate and major bleeding rate was −17 in male (more bleeding than ischemic event rates; p<0.05) and +3 in women (similar bleeding and ischemic event rates; p>0.05), per 1,000 patient-years (Figure).

Figure 1

Conclusions

After an ACS underwent PCI, during DAPT, the ischemic-bleeding balance is different between women and men. In women, the annual incidence of ischemic events was similar to the incidence of bleeding events. However, in men, the incidence of bleeding events is higher than the incidence of ischemic events,

461Modulation of ischemic and bleeding risk by peripheral artery disease after an acute coronary syndrome

Introduction

Peripheral artery disease (PAD) is associated with heightened ischemic and bleeding risk in patients with acute coronary syndrome (ACS). With this study from real-life patients, we try to analyze the balance between ischemic and bleeding risk during treatment with dual antiplatelet therapy (DAPT) after an ACS according to the presence or not of PAD.

Methods

The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients with and without PAD. The impact of prior PAD in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction (AMI), whereas for bleeding risk we have considered major bleeding (MB) defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal.

Results

From the 26,076 ACS patients, 1,600 have PAD (6.1%). Patients with PAD were older, and with more cardiovascular risk factors. DAPT with prasugrel/ticagrelor was less frequently prescribed in patients with PAD in comparison with the rest of the population (8.2% vs 22.8%, p<0.001). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), and 640 AMI (2.5%) and 685 MB (2.6%) were reported. After propensity-score matching, we obtained two matched groups of 1,591 patients. Patients with PAD showed a significant higher risk of both AMI (sHR 2.17, 95% CI 1.51–3.10, p<0.001) and MB (sHR 1.51, 95% CI 1.07–2.12, p=0.018), in comparison with those without PAD. The cumulative incidence of AMI was 63.9 and 29.8 per 1,000 patients/year in patients with and without PAD, respectively. The cumulative incidence of MB was 55.9 and 37.6 per 1,000 patients/year in patients with and without PAD, respectively. The rate difference per 1,000 patient-years for AMI between patients with and without PAD was +34.1 (95% CI 30.1–38.1), and for MB +18.3 (16.1–20.4). The net balance between ischemic and bleeding events comparing patients with and without PAD was positive (+15.8 per 1,000 patients/year, 95% CI 9.7–22.0).

Conclusions

PAD was associated with higher ischemic and bleeding risk after hospital discharge for ACS treated with DAPT. However, the balance between ischemic and bleeding risk was positive for patients with PAD in comparison with patients without PAD. As summary, ACS patients with PAD had an ischemic risk greater than the bleeding risk.

P4623Impact of left ventricular ejection fraction in ischemic and bleeding risk after an acute coronary syndrome

Introduction

Even though left ventricular ejection fraction (LVEF) is a well-documented strong predictor of mortality after an acute coronary syndrome (ACS), its differential impact on the ischemic and bleeding risk of hemorrhage and ischemia is not well established. The aim of this study was to assess the impact of LVEF, measured by echocardiography, on the risk of acute myocardial infarction (AMI) and major bleeding (MB) after hospital discharge for ACS, during treatment with dual antiplatelet therapy (DAPT).

Methods

The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. From the initial merged data set, that contained 26,076 patients, we have excluded those without data about LVEF. So the final cohort was composed by 20,518 patients. The impact of LVEF in the ischemic and bleeding risk was assessed by a multivariable competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. All those variables with statistical (p<0.05) or clinical significance for the association with AMI and MB were included in the analysis. Follow-up time was censored by DAPT suspension/withdrawal.

Results

During a mean follow-up of 12.2±5.2 months, 789 patients died (3.8%), 431 had an AMI (2.1%) and 537 had a MB (2.6%). The mean of LVEF was 53.2% ± 10.7%. Only 15.5% of patients had LVEF <40% (n=3,179). As the LVEF decreased, the risk of AMI increased, whereas the behavior of the risk of MB was more heterogeneous (Figure). After a multivariable adjustment, LVEF (as continuous variable) was significantly associated with AMI (sHR 0.98, 95% CI 0.98–0.99; p=0.010), but not with MB (sHR 1.00, 95% CI 0.99–1.01; p=0.270). After stratifying by LVEF groups (≥ vs <40%), we found an association between LVEF and AMI (sHR 1.40, 95% CI 1.10–1.76; p=0.005), but not between LVEF and bleeding (HR 0.85, 95% CI 0.67–1.08; p=0.185).

Conclusions

After an ACS, as the LVEF decreases, there is an increase in ischemic risk, but not in bleeding risk. A LVEF <40% was independently associated with higher risk of AMI, but not with higher risk of MB.

P877Comparing the MINOCA and MIOCA patients risk profile and prognosis according to definitions of 2016 ESC position paper

Introduction

MINOCA (myocardial infarction with non-obstructive coronary arteries) has been recently redefined by the last ESC guidelines. The aim of this study is to analyze clinical profile and long-term prognosis of these patients.

Methods

Retrospectively, between 1/2010 and 12/2016 all consecutive patients with the definitive diagnosis of MI in tertiary center were included in this observational study. Patients with unstable angina with non-obstructive coronary artery disease and those who died in-hospital were excluded. Patients were stratified according to the number of significant coronary vessel disease seen by coronary angiography into: 0 (MINOCA); 1; 2; ≥3 vessels. The definition of MINOCA was based on dedicated the 2016 ESC Working Group position paper.

Patients with MINOCA were compared to their counterpounds (MIOCA; MI with obstructive CAD) regarding baseline clinical characteristics, on-admission and laboratory data and treatment at hospital discharge. The prognostic meaning of MINOCA vs MIOCA was ascertained by comparing the composite endpoint (re-ACS, stroke and death) rate among groups, using Kaplan-Meier and multivariate Cox regression analyses.

Results

13.8% (n=597) pts were classified as MINOCA. They were older and more frequently women than the obstructive group. MINOCA group also had a worse cardiovascular risk profile than pts with obstructive coronary lesions. They were associated more frequently with atrial fibrillation during hospitalization (11.2% vs. 6.8%, p<0.01). Peak of troponin I was lower in the MINOCA group [median 12 (IQR: 1.4–42.0 vs 20 (2.3–95.5), p<0.01]. MINOCA pts had more frequently a previous history of depression (34.1% vs 19.3%, p<0.01), and malignancy (9.2% vs. 7.6%, p=0.18).

During 15 months (IQR: 12,3–25,5), 613 (14.2) pts had a new ACS, stroke or died (251 pts developed a new ACS, 81 had stroke, and 281 died). The incidence of the composite endpoint was 4.2% in the MINOCA pts, 4.1% in pts with 1-significant coronary vessel disease, 6.3% in the 2-significant coronary vessel disease, and 9.5% in the ≥3-significant coronary vessel disease (p<0.01) (Figure). After adjusting for age, ACS type, sex, Killip class, age, HTA, DM, stroke, peripheral artery disease, smoking, prior CAD, COPD, prior malignancy, baseline hemoglobin and creatinine values, DES vs BMS, history of atrial fibrillation, and treatment at discharge, and considering MINOCA as a reference group, HR for the composite endpoint was 1.02 (0.60–1.78; p=0.93) for the 1-vessel group, 1.3 (0.7–2.2; p=0.41) for the 2-vessels group, and 1.6 (0.93–2.8; p=0.08) for the ≥3-vessels group.

Figure 1. Composite endpoint

Conclusions

In the present cohort MINOCA was approximately found in one of each 14 patients admitted with MI. These patients had worse CV risk profile and more history of depression. MINOCA pts have similar prognostic impact in terms of hospitalization for a new ACS, stroke and death than the obstructive group.

462Impact of severe anemia (hemoglobin <10 g/dl) in the ischemic-bleeding profile during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome

Introduction

Anemia is strongly associated with increased risk of morbidity and mortality in patients after acute coronary syndromes (ACS). The aim of our study was to determine, after matching the baseline characteristics, the bleeding-ischemic risk profile during treatment with Dual Antiplatelet Therapy (DAPT) of patients with severe anemia (hemoglobin <10 g/dL) after an ACS undergoing Percutaneous Coronary Intervention (PCI).

Methods

The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients according to presence or not of severe anemia (hemoglobin <10 g/dL). The impact of severe anemia in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction, whereas for bleeding risk we have considered major bleeding defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal.

Results

From the 26,076 ACS patients, 630 had severe anemia (2.4%). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), 640 had myocardial infarction (2.5%) and 685 had major bleeding (2.6%). After propensity-score matching, we obtained two matched groups (with hemoglobin < and ≥10 g/dL) of 621 patients. In comparison with patients without severe anemia, patients with hemoglobin <10 g/dL had similar risk of myocardial infarction (sHR 1.37, 95% CI 0.82–2.31, p=0.231) with higher risk of major bleeding (sHR 1.89, 95% CI 1.18–2.72, p=0.006). After propensity score matching, the cumulative incidence of myocardial infarction was 6 and 5 per 100 patients/year in patients with and without severe anemia, respectively, during DAPT. And the cumulative incidence of major bleeding was 12 and 6 per 100 patients/year in patients with and without severe anemia, respectively. The difference between myocardial infarction rate and major bleeding rate was −6 in patients with severe anemia (more bleeding than ischemic event rates; p<0.05) and −1 in patients with hemoglobin ≥10 g/dL (similar bleeding and ischemic event rates; p>0.05), per 100 patient-years (Figure).

Conclusions

After an ACS underwent PCI, during DAPT, the ischemic-bleeding balance of patients with severe anemia (hemoglobin <10 g/dL) is not favorable. In those patients, a short-term DAPT (<6 months) should be recommended.