Bleeding after percutaneous coronary intervention and selection of candidates for long-term dual antithrombotic treatment

Background

The European Society of Cardiology recommends addition of a second antithrombotic drug (a P2Y12 inhibitor or rivaroxaban 2.5 mg twice daily) on top of aspirin in selected patients with chronic coronary syndrome (CCS) at high residual risk of ischemic events. However, this treatment increases bleeding risk, and identifying subsets of patients with the most favorable trade-off between ischemic and bleeding risk thus is essential. We hypothesized that patients undergoing percutaneous coronary intervention (PCI) who tolerate subsequent dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) without any bleeding complications selected themselves as candidates for prolonged dual antithrombotic therapy.

Methods and results

We included 30,531 patients with CCS treated with dual antiplatelet therapy after first-time PCI with a drug-eluting stent in Western Denmark (3.5 million inhabitants) from 1999 to 2018. Of these, 1,220 (4%) were hospitalized for bleeding within one year after PCI (bleeders) and 29,311 (96%) were not (non-bleeders). Patients were followed for maximum nine years (median follow-up 5.4 years). Bleeders had an increased nine-year risk of death (adjusted hazard ratio [aHR] 1.54, 95% CI 1.37–1.73) and hospitalization for bleeding (aHR 2.53, 95% CI 2.20–2.90). These associations were particularly strong for women. Looking at types of bleeding, the strongest predictors of death were gastrointestinal bleeding, cerebral bleeding, and anemia due to bleeding. Risks of myocardial infarction and ischemic stroke did not differ between bleeders and non-bleeders (Table). We then stratified non-bleeders according to their thromboembolic risk using the CHADS-P2A2RC score – a validated clinical risk prediction model developed to estimate thromboembolic risk in patients without atrial fibrillation. Non-bleeders with a high estimated thromboembolic risk (CHADS-P2A2RC score ≥4) had higher nine-year risks of myocardial infarction (hazard ratio [HR] 1.88, 95% CI 1.78–2.07), ischemic stroke (HR 3.02, 95% CI 2.66–3.43), hospitalization for bleeding (HR 1.98, 95% CI 1.81–2.16) and, in particular, death (HR 4.48, 95% CI 4.21–4.77) than non-bleeders with a low-to-moderate predicted risk (CHADS-P2A2RC score <4).

Conclusions

Patients with CCS experiencing a bleeding event during the first year after first-time PCI had a substantially higher long-term risk of death and recurrent bleeding, but not a higher risk of ischemic events. Therefore, bleeding events during the first year after PCI may guide the preclusion of selected patients from long-term dual antithrombotic therapy. Among non-bleeders, the risk of ischemic events rose proportionately more than the risk of bleeding when comparing high-risk with low-risk patients. This is an important finding for clinicians, for whom accurate identification of patients at highest risk of ischemic events is an essential step in treatment allocation.

Funding Acknowledgement

Type of funding sources: None.

Microvascular complications, coronary artery disease and the risk of cardiovascular disease in diabetes patients undergoing coronary angiography: a cohort study from the Western Denmark Heart Registry

Background

Diabetes is associated with an increased risk of both microvascular macrovascular complications. The association between microvascular disease and cardiovascular risk, however, is less explored.

Aims

We aimed to estimate the cardiovascular risk associated with microvascular disease in diabetes patients with and without coronary artery disease.

Methods

We included every patient who underwent coronary angiography in Western Denmark between 2003–2016. Patients were stratified by microvascular disease (defined as diagnosis retinopathy, nephropathy, or peripheral neuropathy) and coronary artery disease by angiography. Outcomes included major adverse cardiovascular events (myocardial infarction, ischemic stroke, and cardiac death) as a combined outcome and as separate outcomes. Patients were followed for a maximum of 10 years. We estimated 10-year cumulative incidence of each outcome. Incidence rate ratios (IRR) were estimated by a modified Poisson regression model using diabetes patients with neither microvascular disease nor coronary artery disease as reference.

Results

We included 19,295 patients with diabetes, of whom 1,268 (6.6%) had microvascular disease, 10,161 (52.7%) had coronary artery disease, 3,113 (16.3%) had both microvascular disease and coronary artery disease, and 4,753 (24.6%) had neither microvascular nor coronary artery disease. Median follow-up was 5.9 years (interquartile range 3.3–9.0) Patients with microvascular disease had an increased risk of major adverse cardiovascular events compared to diabetes patients with neither microvascular disease nor coronary artery disease (13.6% versus 10.0%, adjusted IRR 1.45, 95% CI 1.19–1.77, Figure 1). This increased risk was driven by a 3.9% higher risk of ischemic stroke (adjusted IRR 1.53, 95% CI 1.14–2.05, Figure 2), while microvascular disease was not associated with an increased risk of myocardial infarction (adjusted IRR 1.08, 95% CI 0.72–1.62) or cardiac death (adjusted IRR 0.99, 95% CI 0.63–1.56). Patients with both microvascular disease and coronary artery disease had the highest risk of major adverse cardiovascular events (29.3%, adjusted IRR 3.06, 95% CI 2.67–3.50).

Conclusion

Microvascular disease in diabetes patients without angiographic coronary artery disease is associated with an increased cardiovascular risk. However, this was driven by a higher risk of ischemic stroke than by higher rates of myocardial infarction or cardiac death. In fact, diabetes patients with microvascular disease but no coronary artery disease had the same risk of ischemic stroke as those with combined microvascular disease and coronary artery disease.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Aarhus University Hospital

Causes of excess mortality in diabetes patients without coronary artery disease

Background

Diabetes (DM) patients without coronary artery disease (CAD) by coronary angiography have a similar risk of myocardial infarction and cardiac death as non-DM patients without CAD. Yet, even with absence of CAD, patients with DM have higher mortality compared to non-DM patients.

Aims

To examine the underlying causes of death in patients undergoing coronary angiography depending on DM and CAD.

Methods

We included every patient with no previous history of CAD who underwent coronary angiography in Western Denmark between 2003–2016. Patients were stratified by DM and CAD and followed for a maximum of 10 years. We estimated the 10-year cumulative risk of all-cause death and cause-specific death. Causes of death were categorized as “cardiovascular”, “pulmonary”, “cancer”, “renal”, “bleeding-related”, and “other” based on ICD-10 codes listed as underlying causes of death obtained from death certificates. Deaths where DM was listed as the underlying cause of death (i.e. ICD-10 code DE1) were included in the category “other”.

Results

We included 132,432 patients, of whom 33% had neither DM nor CAD, 5% had DM only, 51% had CAD only, and 11% had both DM and CAD. Mean age was 64 years. Median follow-up was 6.3 year (inter-quartile range 3.8–10.0). During follow-up, 35,036 (26.5%) patients died. Patients with both DM and CAD had the highest 10-year mortality (47.4%, 95% CI 46.3–48.4), followed by CAD only (33.3%, 95% CI 32.8–33.7), DM only (30.7%, 95% CI 29.3–32.2), and patients with neither DM nor CAD (21.6%, 95% CI 21.1–22.1). The proportion of cardiovascular deaths were similar in patients with DM only (29.2%, 95% CI 27.0–31.5, Figure) and patients with neither DM nor CAD (29.7%, 95% CI 28.8–30.7). Patients with DM were more likely to die from causes categorized as “other” compared to patients with neither DM nor CAD [38.4% (95% CI 36.0–40.9) versus 30.2% (95% CI 29.3–31.2)]. Among patients with DM only, 43.7% of deaths classified as “other” were attributable to DM-related complications such as ketoacidosis and diabetic nephropathy.

Conclusion

Despite absence of CAD, DM remained associated with increased mortality. Excess mortality was primarily driven by patients dying of DM-related microvascular complications and ketoacidosis. Thus, despite absence of CAD, patients with DM require continued preventative measures to reduce DM-related mortality.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Aarhus University Hospital

Trends in mortality and ischemic outcomes in patients with ST-segment elevation myocardial infarction following implementation of a primary percutaneous coronary intervention strategy, 2003–2017

Introduction

In Denmark, primary percutaneous coronary intervention (pPCI) has served as the national reperfusion strategy in ST-segment elevation myocardial infarction (STEMI) since 2003. Since then, extensive changes in management and treatment of patients with STEMI have been introduced. We investigated the temporal trends in one-year mortality and ischemic outcomes after STEMI.

Methods

We included all first-time STEMI patients treated with pPCI in Western Denmark from 2003 to 2017. Patients were categorized into four time periods based on year of pPCI treatment (2003–2006, 2007–2010, 2011–2014, 2015–2017) and followed for one year. Outcomes included all-cause death, recurrent myocardial infarction (MI: follow-up started after 30 days post-pPCI since the validity of recurrent MI is low in the first 30 days), and ischemic stroke. We also identified a sex and age matched comparison cohort without prior cardiovascular disease from the Western Denmark general population. Groups were compared using sex- and age-adjusted hazard ratios (aHRs) by Cox regression with the first period as reference.

Results

A total of 18,538 STEMI patients and 92,690 individuals from the general population were included. One-year mortality in STEMI patients decreased from 10.8% in 2003–2006 to 7.8% in 2015–2017 (aHR 0.70, 95% CI 0.60–0.80), while it was steady in the general population cohort (figure). The one-year risk of recurrent MI and ischemic stroke also decreased from 2003–2006 to 2015–2017 (MI: 3.5% vs. 2.4%, aHR: 0.66, 95% CI 0.51–0.86; ischemic stroke: 2.5% vs. 1.9%, aHR 0.58, 95% CI 0.42–0.80). These improvements coincided with increased up-take of evidence-based treatments, especially drug-eluting stents (39% vs. 90%), high-intensity statins (3% vs. 87%), and newer antiplatelet agents.

Conclusions

From 2003 to 2017, the one-year risk of death, recurrent MI, and ischemic stroke decreased substantially among patients with STEMI. These improvements occurred simultaneously with the gradual implementation of evidence-based guideline-directed treatments.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Aase and Ejnar Danielsen foundation

Diabetes, coronary artery disease, and risk of dementia – a cohort study from Western Denmark

Background

Diabetes patients have a higher risk of both ischemic stroke and dementia compared to non-diabetes patients. Coronary artery disease (CAD) is associated with an increased risk of ischemic stroke. We hypothesized that diabetes and CAD are independent, and additive, risk factors for ischemic stroke and dementia.

Purpose

We examined the risk of dementia and ischemic stroke in diabetes and non-diabetes patients with and without CAD by coronary angiography.

Methods

We conducted a cohort study of all patients ≥65 years, who underwent coronary angiography between 2003–2016 in Western Denmark. Patients diagnosed with dementia or early cognitive decline at the time of CAG were excluded. Patients were stratified by diabetes and CAD. Outcomes were dementia and ischemic stroke. We estimated the cumulative incidence of a combined endpoint of dementia and ischemic stroke accounting for the competing risk of death. Follow-up was capped at the 75th percentile of overall follow-up (9.2 years). We estimated adjusted hazard ratios (aHRs) using patients without diabetes and CAD as reference. We also examined the association between extent of CAD and dementia in subgroup analysis of diabetes patients.

Results

A total of 62,372 patients were included, of whom 10,417 (16.7%) had diabetes and 43,023 (69.0%) had obstructive CAD. Median follow-up was 5.8 years. Patients with both diabetes and CAD had the highest risk of dementia (aHR 1.47, 95% CI 1.27–1.71), including Alzheimer's dementia (aHR 1.26, 95% CI 1.01–1.56) and vascular dementia (aHR 2.60, 95% CI 1.78–3.80), as well as ischemic stroke (aHR 2.02, 95% CI 1.77–2.32). Patients with either diabetes or CAD were at intermediate risk of dementia and ischemic stroke (Figure). We did not find a significant trend between the extent of CAD and risk of dementia in diabetes patients (p for trend=0.0687).

Conclusions

Both diabetes and CAD were independent risk factors of dementia and ischemic stroke in patients ≥65 years after angiography. Patients with combined diabetes and CAD had a particularly high risk of cognitive impairment and ischemic stroke.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Diabetes is not a risk factor for myocardial infarction in patients without coronary artery disease

Background

Diabetes is considered a risk factor for myocardial infarction (MI). However, we have previously found that diabetes was not a short-term risk factor for MI in the absence of obstructive coronary artery disease (CAD).

Purpose

As long-term data are not available, we aimed to assess adverse cardiac events in patients with and without diabetes stratified by CAD up to 11 years after coronary angiography.

Methods

We conducted a cohort study of patients undergoing coronary angiography from 2003 to 2012 and followed them by cross-linking Danish health registries. Patients were stratified according to the presence/absence of CAD and diabetes. Outcomes included MI, cardiac death, all-cause death, and coronary revascularization.

Results

A total of 86,202 patients were included (diabetes: n=12,652). Median follow-up was 8.8 years. Using patients with neither CAD nor diabetes as reference (cumulative MI incidence 2.6%), the risk of MI was similar for patients with diabetes alone (3.2%; hazard ratio 1.202, 95% CI: 0.996–1.451), was increased for patients with CAD alone (9.3%; hazard ratio 2.75, 95% CI: 2.52–3.01), and was highest for patients with both CAD and diabetes (12.3%; hazard ratio 3.79, 95% CI: 3.43–4.20), see Figure. Similar associations were observed for cardiac death and coronary revascularization.

Conclusions

Diabetes patients without CAD by coronary angiography have a similar risk of MI compared to patients with neither CAD nor diabetes. In the presence of CAD, however, diabetes increases the risk of MI.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): The Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.

Microvascular disease, peripheral artery disease, and the risk of lower limb amputation

Background

Peripheral artery disease (PAD) is the leading cause of non-traumatic lower limb amputation. Microvascular disease (peripheral neuropathy, nephropathy, or retinopathy) increases the risk of lower limb amputation in patients with established PAD.

Purpose

We estimated risk of lower limb amputation associated with microvascular disease and PAD in a Danish cohort.

Methods

We conducted a population-based cohort study of every person living in Western Denmark aged 50–75 years on January 1, 2012 and followed them for 7 years. People with previous lower limb amputation were excluded. People were stratified by the presence of microvascular disease (peripheral neuropathy, nephropathy, or retinopathy) and PAD (peripheral atherosclerosis including intermittent claudication, or previous lower limb revascularization). We estimated the 7-year cumulative incidence and hazard ratio (HR) of lower limb amputation using individuals with neither microvascular disease nor PAD as reference. We also provide a sex-specific analyses and estimated the population attributable fraction of amputation associated with male sex.

Results

We included 933,597 individuals, of whom 16,007 had microvascular disease, 18,400 had PAD, and 1,789 had both microvascular disease and PAD. Patients with either microvascular disease (3.7%) or PAD (3.9%) had similar unadjusted 7-year risks of lower limb amputation (Figure). Microvascular disease (adjusted HR 3.21, 95% CI 2.86–3.59) and PAD (adjusted HR 7.37, 95% CI 6.68–8.14) increased the risk of lower limb amputation separately in adjusted analysis. Individuals with both microvascular disease and PAD had the highest risk of amputation (adjusted HR 11.82, 95% CI 10.11–13.80). While the relative impact of microvascular disease and PAD were similar in men and women, men had increased risk of amputation compared to women, in absolute terms. The population attributable fraction of amputations associated with male sex was 31%.

Conclusion

Microvascular disease and PAD are independently associated with a 3-fold and 7-fold increase of amputation rate, respectively. Combined, microvascular disease and PAD had an additive effect constituting a 12-fold amputation risk. Amputation risk was higher in men than in women, with 3 in 10 lower limb amputations in Western Denmark attributable to male sex.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Ten-year cardiovascular risk in diabetes patients without of coronary artery disease – a Danish cohort study

Background

Patients with diabetes without obstructive coronary artery disease (CAD) by coronary angiography (CAG) have a risk of myocardial infarction (MI) similar to that of non-diabetes patients without CAD. Their cardiovascular risk compared to the general population is unknown.

Purpose

We examined the 10-year risks of myocardial infarction (MI), ischemic stroke, and death in diabetes patients without CAD after CAG compared to the general population.

Methods

We included all diabetes patients without obstructive CAD examined by CAG from 2003–2016 in Western Denmark and an age and sex matched comparison group, sampled from the general population in Western Denmark without previous history of coronary heart disease. Outcomes were MI, ischemic stroke, and death. The 10-year cumulative incidences were estimated. Adjusted hazard ratios (HRs) were estimated by stratified Cox regression using the general population as the reference group.

Results

We identified 5,760 diabetes patients without obstructive CAD and 29,139 individuals from the general population. Median follow-up was 7 years with 25% of participants followed for up to 10 years. Diabetes patients without obstructive CAD had an almost similar 10-year risk of MI (3.2% vs 2.9%, adjusted HR 0.91, 95% CI 0.70–1.17, Figure) compared to the general population cohort. Diabetes patients had an increased risk of ischemic stroke (5.2% vs 2.2%, adjusted HR 1.88, 95% CI 1.48–2.39), and death (29.7% vs 17.9%, adjusted HR 1.41, 95% CI 1.29–1.54). The duration of diabetes was associated with increased cardiovascular risk.

Conclusions

Absence of obstructive CAD by CAG in patients with diabetes ensures a low MI risk similar to the general population, but diabetes patients still have an increased risk of ischemic stroke and all-cause death despite absence of CAD.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Risk of lower limb amputation in diabetes patients with and without coronary artery disease – a cohort study from Western Denmark

Background

Diabetes patients are at greater risk of lower limb amputation due to a higher risk of peripheral artery disease (PAD) and peripheral neuropathy. The effect of concomitant coronary artery disease (CAD) is less explored.

Purpose

We examined the risk of PAD, lower limb revascularization, and lower limb amputation in diabetes and non-diabetes patients with and without CAD examined by coronary angiography.

Methods

We included all patients who underwent coronary angiography between 2003–2016 in Western Denmark. Patients with a history of PAD or previous lower limb revascularization or amputation were excluded. Patients were stratified by diabetes and CAD status and followed in prospective registries for a maximum of 10 years. Outcomes were PAD, lower limb revascularization, and lower limb amputation. We estimated 10-year cumulative incidence and adjusted hazard ratios (aHR) using patients with neither diabetes nor CAD as reference. We also examined the effect of CAD extent, insulin treatment, and duration of diabetes in the diabetes group.

Results

A total of 118,787 coronary angiography patients were included of whom 17,482 (14.7%) had diabetes. Median follow-up was 6.8 years. Patients with both diabetes and CAD had the highest risk of PAD (aHR 3.90, 95% CI 3.55–4.28), lower limb revascularization (aHR 4.61, 95% CI 3.85–5.52), and lower limb amputation (aHR 9.49, 95% CI 7.27–12.39), compared with patients with neither diabetes nor CAD. Extent of CAD, insulin treatment, and duration of diabetes were all associated with increased risks of PAD and amputation in the diabetes group. CAD only patients had higher 10-year risk of PAD compared to diabetes only patients (7.9% versus 6.9%), but had lower risk of amputation (0.6% versus 2.4%, Figure). CAD only patients were most often amputated at hip/femur level, while diabetes only patients most often were amputated at ankle/foot/toe level.

Conclusions

Presence of CAD in patients with diabetes was an indicator of high risk of PAD and lower limb amputation, and the risk depended on severity of both CAD and diabetes.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

287Diabetes mellitus is a risk factor for ischemic stroke in patients with and without coronary artery disease after coronary angiography

Background

Diabetes (DM) and non-DM patients without coronary artery disease (CAD) by coronary angiography (CAG) have the same low risk of myocardial infarction.

Purpose

To study whether DM patients without CAD have the same risk of ischemic stroke as patients with neither DM nor CAD.

Methods

We conducted a cohort study of patients, who underwent CAG between 2004 and 2012 in the Western Denmark Heart Registry. Patients previously diagnosed with ischemic stroke or atrial fibrillation (AF) and those treated with an oral anticoagulant were excluded. Patients were stratified according to presence of DM and CAD. Follow-up started 30 days after CAG. We computed event rates and adjusted incidence rate ratios (IRRs) using patients with neither DM nor CAD as reference.

Results

A total of 68,829 patients were included. Median follow-up was 4.0 years. Patients with both DM and CAD were at the highest risk of ischemic stroke (1.25 events per 100 person-years; adjusted IRR 2.10, 95% CI 1.77–2.48) (Figure 1). Patients with CAD alone (0.70 events per 100 person-years; adjusted IRR 1.29, 95% CI 1.12–1.48) or DM alone (0.84 events per 100 person-years; adjusted IRR 1.79, 95% CI 1.41–2.26) were at intermediate risk while patients with neither DM nor CAD (0.46 events per 100 person-years) were at lowest risk. Among DM patients, extent of CAD was further predictive of risk (ptrend<0.001).

Figure 1

Conclusions

Not only CAD but also DM independently predict the risk of ischemic stroke after CAG. Their combination further increases the risk of ischemic stroke depending on the extent of CAD.

P1527The applicability of the dual pathway approach criteria after coronary angiography

Background

The combination of aspirin and low-dose rivaroxaban (dual pathway approach, DPA) has been approved for high-risk patients with stable coronary artery disease (CAD) in the COMPASS trial. Patients with CAD combined with ≥1 DPA criteria, defined as peripheral artery disease, renal failure, heart failure, or diabetes, have been proposed as high-risk patients eligible for DPA.

Purpose

To determine the prevalence of patients meeting the DPA criteria and the association with major adverse cardiovascular events (MACE) in patients with stable CAD after coronary angiography (CAG). Further, to evaluate use of the DPA criteria in CAD patients meeting the inclusion criteria in the COMPASS trial.

Methods

We studied patients included in the Western Denmark Heart Registry after examination by CAD 2004–11. Patients without CAD or myocardial infarction (MI) <1 year before or 30 days after CAG were excluded. Patients were stratified according to 0 or ≥1 DPA criteria and being eligible/ineligible for the COMPASS trial. Event rates and incidence rate ratios (IRRs) of MACE (cardiac death, ischemic stroke, and MI) were estimated.

Results

Of 80,071 patients undergoing CAG, 18,689 (23%) patients had stable CAD. According to the DPA criteria, 7,730 patients (10%) were DPA eligible. Rates of MACE were 1.98 (95% CI 1.86–2.34) events per 100 person-years among DPA ineligible patients and 4.26 (95% CI 4.04–4.50) events per 100 person-years among DPA eligible patients (IRR 2.15, 95% CI 1.98–2.34). When stratifying patients according to eligibility in the COMPASS inclusion criteria, COMPASS eligible patients with 0 DPA criteria and COMPASS ineligible patients with ≥1 DPA criteria were at intermediate risk compared to patients meeting both (high risk) or none (low risk) of these criteria (Figure 1).

Figure 1

Conclusion

In a cohort of consecutive patients undergoing CAG, 1 in 10 patients would be eligible for DPA according to the DPA criteria. Patients with stable CAD and ≥1 DPA criteria had >2-fold higher rate of MACE than CAD patients without any DPA criteria.