Prevalence and impact of TWILIGHT criteria in all-comer patients undergoing percutaneous coronary intervention

Background

The Ticagrelor with Aspirin or Alone in High-Risk Patients after Coronary Intervention (TWILIGHT) randomized clinical trial demonstrated that in selected high risk patients who took ticagrelor and aspirin for 3 months after percutaneous coronary intervention (PCI), continuing ticagrelor alone was associated with significantly less bleeding events than ticagrelor plus aspirin and did not lead to ischemic harm over a period of 1 year (1).

The prevalence and risk of adverse events of patients fulfilling the TWILIGHT inclusion criteria in real-world setting is unclear.

Purpose

To elucidate the prevalence and prognosis of patients fulfilling the TWILIGHT inclusion criteria.

Methods

Patients that received at least one drug eluting stent in a coronary artery at a large tertiary center (Mount Sinai Hospital, New York) were considered for inclusion. As in the TWILIGHT trial, individuals on chronic oral anticoagulation treatment, with STEMI, cardiogenic shock, on dialysis, with prior stroke, or platelet count <100,000 were excluded. Patients were stratified in two groups: 1) TWILIGHT-like patients, who met at least one clinical (age ≥65 years, female sex, established vascular disease, diabetes mellitus, estimated glomerular fraction rate <60mL/min, acute coronary syndrome with troponin increase) and one angiographic (multivessel coronary artery disease [CAD], stent length >30mm, thrombotic target lesion, bifurcation requiring 2 stents, left main or proximal left anterior descending artery lesion, atherectomy device use, SYNTAX score ≥23) TWILIGHT inclusion criterion; 2) Non-TWILIGHT-like patients, who did not fulfil at least one clinical and one angiographic TWILIGHT inclusion criterion.

The primary outcome was a composite of death, myocardial infarction (MI), stroke. Secondary outcomes included bleeding, components of the primary outcome, target vessel and target lesion revascularization, stent thrombosis. All events were assessed at 1 year after PCI.

Results

Out of 30,470 patients undergoing PCI between 2012 and 2019, 13,236 were included in the current analysis. TWILIGHT criteria were met in 11,018 (83%) patients. Established vascular disease and multivessel CAD were the most frequently fulfilled criteria. At 1 year, TWILIGHT-like patients were at higher risk for the primary outcome (3.2% vs 1.1%, HR 2.85, 95% CI 1.83–4.44), severe bleeding (3.3% vs 1.8%, HR 1.86, 95% CI 1.32–2.62), all-cause death (1.4% vs 0.4%, HR 3.63, 95% CI 1.70–7.77), myocardial infarction (1.8% vs 0.6%, HR 2.81 95% CI 1.56–5.04), TVR (7.8% vs 4.1%, HR 1.94, 95% CI 1.53–2.47), TLR (5.1% vs 1.7%, HR 2.98 95% CI 2.07–4.29). Stent thrombosis and stroke rate were generally low and did not differ between patients meeting or not the TWILIGHT inclusion criteria.

Conclusion

Among all-comer patients undergoing PCI, the fulfillment of the TWILIGHT inclusion criteria is frequent and is associated with a higher risk of death, ischemic and bleeding complications

Funding Acknowledgement

Type of funding sources: None.

Impact of different antiplatelet therapy cessation modes on outcomes in patients treated with ticagrelor with or without aspirin after PCI: the twilight-antiplatelet cessation study

Background

The Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention (TWILIGHT) trial showed that a regimen consisting of a 3-month dual antiplatelet therapy (DAPT) followed by ticagrelor monotherapy reduces the rate of bleeding events without increasing ischemic complications compared with standard DAPT [1]. Previous studies, such as Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients (PARIS) demonstrated how deviation or cessation of the prescribed antiplatelet regimen might negatively affect clinical outcomes [2].

Purpose

The proposed analysis aims to assess the impact of different antiplatelet therapy cessation patterns on ischemic and bleeding outcomes in patients treated with ticagrelor with or without aspirin after percutaneous coronary intervention (PCI).

Methods

All 7,119 patients randomized at 3 months post-PCI in the TWILIGHT study will be included. The analyses will be conducted separately in the two treatment arms (ticagrelor plus placebo and ticagrelor plus aspirin). According to the PARIS study definitions and as prespecified in the TWILIGHT trial protocol, the occurrence of the three following antiplatelet cessation modes will be assessed: 1) discontinuation (e.g., caused by intolerable side effects or because of a safety concern); 2) interruption (temporary, <14 days, because of surgical or other invasive procedures); 3) disruption (due to non-compliance or bleeding).

The primary endpoint will be the composite of all-cause death, myocardial infarction (MI), or stroke at 12 months after randomization. The key secondary endpoint will be BARC type 2, 3 or 5 bleeding. Other secondary endpoints will include the components of the primary endpoint, cardiovascular death, definite or probable stent thrombosis and BARC types 3 or 5 bleeding. The number of events will be estimated according to the antiplatelet cessation status before the clinical event. Hazard ratios and 95% confidence intervals will be generated using Cox proportional hazards models including antiplatelet therapy cessation as a time-updated variable. If more than one cessation event occurred during follow-up, the antiplatelet therapy cessation category will change only if the more recent mode is worse than the previous: disruption will have priority over interruption, which in turn will have priority over discontinuation. Patients without cessation events will represent the reference group. All adverse events and episodes of antiplatelet cessation were independently adjudicated.

Results

The results of this analysis will be presented for the first time at ESC 2022.

Conclusion

This prespecified analysis of the TWILIGHT study will show for the first time the impact on clinical outcomes of different antiplatelet therapy cessation modes when a regimen of Ticagrelor with our without aspirin is prescribed after PCI.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Astra Zeneca, United Kingdom

Safety and efficacy of biodegradable polymer biolimus-eluting stents in patients with non-ST-elevation acute coronary syndrome: a pooled analysis of GLASSY and TWILIGHT

Background

Biodegradable polymer (BP) drug-eluting stents (DES) have shown similar safety and efficacy compared with second-generation durable polymer (DP)-DES in several randomized trials and meta-analyses. However, study participants were generally maintained on a standard dual antiplatelet therapy (DAPT) for at least 6 months after percutaneous coronary intervention (PCI). Therefore, the differences in thrombogenicity between these two stent technologies may have been unappreciated, especially among patients with acute coronary syndrome (ACS).

Purpose

We aimed to compare the safety and efficacy of BP Biolimus-Eluting Stent (BP-BES) versus 2nd generation DP-DES among ACS patients undergoing PCI and receiving ticagrelor alone or in combination with aspirin.

Methods

We pooled individual patient-level data from two randomized controlled trials, the Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention (TWILIGHT, n=9,006) (1) and the GLOBAL LEADERS Adjudication Sub-Study (GLASSY, n=7,585) (2). In order to reduce biases related to trial design differences, only NST-ACS patients not fulfilling any exclusion criterion of both studies were included and 2 separate analysis for short (0 to 3 months after PCI) and long-term (3 to 12 months after PCI) outcomes were performed. Patients were stratified according to the stent used at index PCI (BP-BES vs 2nd generation DP-DES). In both analysis, the primary outcome was major adverse cardiovascular events (MACE, a composite of cardiovascular death, myocardial infarction and definite or probable stent thrombosis); the key secondary outcomes were target-vessel failure (TVF) and BARC 2, 3 or 5 bleeding. Events rate and risk were assessed separately for the two study periods and subsequently 12-months risk estimates were derived by pooling the results of the two analysis.

Results

Out of 7,729 and 6,572 NST-ACS patients included in the two analysis, 2,321 (30%) and 2,211 (33.6%) received a BP-BES, respectively. Among patients treated with BP-BES versus DP-DES, the occurrence of MACE was similar at 3 months after PCI (1.1% vs 1.4%, adjusted HR 0.81, 95% CI 0.51–1.29), while it was significantly lower in the former group between 3 and 12 months (1.7% vs 3.1%, adj. HR 0.46, 95% CI 0.32–0.67) and in the overall period (pooled adjusted HR estimate 0.58, 95% CI 0.43–0.77).

Similarly, significant differences were observed for TVF and BARC 2, 3, or 5 bleeding, whose risk at 12 months was lower among BP-BES than DP-DES patients (pooled adj. HR estimate 0.49, 95% CI 0.38–0.63 and 0.79, 95% CI 0.79, 95% CI 0.65–0.97, respectively).

Conclusion

As compared to 2nd generation DP-DES, BP-BES was associated with a lower risk of MACE, TVF and bleeding among NST-ACS patients undergoing PCI and treated with ticagrelor with or without aspirin. The findings of this analysis are exploratory and need further confirmation.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Biosensors (Singapore)

Effect of aspirin discontinuation according to individualised patient bleeding and ischemic risks after PCI: a TWILIGHT trial sub-analysis

Background

The TWILIGHT trial demonstrated a reduction in BARC 2, 3 or 5 (BARC-235) bleeding without an increase in ischemic events at 1-year in high-risk PCI patients randomized to placebo or aspirin (ASA) on a background of ticagrelor 3-months after PCI. However, the effect of ASA discontinuation according to baseline risk of bleeding and ischemic events remain unclear.

Purpose

To a) develop separate models to predict the risk of bleeding and ischemic events, and b) to assess treatment effect of ASA discontinuation across the risk strata.

Methods

Using the TWILIGHT patient database (N=7,119), two multivariable models, one for BARC-235 bleeding and one for CV death, nonfatal MI or nonfatal ischemic stroke (ischemic endpoint) were developed, and their predictive capacity was assessed. The effect of randomized treatment on bleeding and ischemic events across different patient risk-group categories as determined by the risk scores was investigated.

Results

At 1-year, 350 (5.4%) patients experienced a BARC-235 bleeding event and 258 (3.6%) experienced an ischemic event. Independent predictors of BARC-235 included haemoglobin levels at index PCI, proton-pump inhibitor non-use at discharge, age, liver disease and active smoking (c-statistic 0.64). Independent predictors of the ischemic outcome included a positive troponin ACS, prior CABG, diabetes, age, peripheral artery disease, prior PCI, a history of congestive heart failure, active smoking, the level of index PCI complexity, and prior MI (c-statistic 0.71). The risk of a BARC-235 almost doubled between patients in lower versus higher bleeding risk categories (4.3% versus 7.9%) and ischemic risk more than tripled between patients in lower versus higher ischemic risk categories (2.0% versus 7.0%) (see Figure 1). There was no evidence of a differential treatment effect for dual antiplatelet therapy versus ticagrelor monotherapy across the different risk categories of bleeding (interaction P=0.54) and ischemic risk (interaction P=0.95) (Table 1).

Conclusion

Individual patient bleeding and ischemic risks after PCI can both be readily characterised with good discrimination. The effect of ASA discontinuation in preventing bleeding in ticagrelor-treated patients was consistent regardless of baseline bleeding risk. There was no evidence for increased ischemic events with ASA discontinuation according to baseline ischemic risk.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZenecaIcahn School of Medicine at Mount Sinai

Prasugrel or clopidogrel in patients with acute coronary syndromes at high thrombotic risk: results from the PROMETHEUS study

Background

Potent P2Y12 inhibitors are recommended on top of aspirin in patients presenting with acute coronary syndrome (ACS). However, guideline recommendations suggest that the optimal antithrombotic strategy should be tailored based on patients thrombotic and hemorrhagic risk profile.

Purpose

It is poorly investigated if the benefits derived from potent P2Y12 inhibition in patients with ACS depend on the individual thrombotic risk profile. Our aim was to evaluate if the benefits associated with prasugrel vs. clopidogrel in patients with ACS undergoing percutaneous coronary intervention (PCI) are similar in case of different thrombotic risk profiles.

Methods

PROMETHEUS was a multicenter observational study comparing prasugrel vs. clopidogrel in ACS patients undergoing PCI. According to the 2020 ESC guidelines for non-ST elevation-ACS, patients are defined at high thrombotic risk if presenting with a clinical (diabetes mellitus requiring medication, history of recurrent myocardial infarction [MI], multivessel coronary artery disease [CAD], polyvascular [coronary and peripheral] disease, premature (<45 years) CAD, and chronic kidney disease [estimated glomerular filtration rate <60 ml/min/1.73m2]) and procedural (≥3 stents implanted, ≥3 lesions treated, total stent length >60 mm, complex revascularization [left main PCI, bifurcation or chronic total occlusion]) risk features. The primary endpoint was major adverse cardiac events (MACE), a composite of death, MI, stroke or unplanned revascularization. Hazard ratio (HR) and 95% confidence intervals (CI) were calculated using propensity-stratified analysis to assess the effect of prasugrel vs. clopidogrel and with multivariable Cox regression to evaluate the impact of thrombotic risk.

Results

Among 16065 patients, 4293 were defined at high thrombotic risk and 11772 at low-to-moderate thrombotic risk. Patients treated with prasugrel had less comorbidities and risk factors than those treated with clopidogrel, both in the high and low-to-moderate thrombotic risk strata. Patients at high thrombotic risk had higher rates of both ischemic and bleeding events at 90 days and at 1 year. Patients treated with prasugrel had a lower adjusted risk of MACE at 1 year (HR 0.86, 95% CI 0.77–0.96), with no significant interaction between effect estimates and thrombotic risk. However, after stratifying the study population by the number of risk factors, there was a significant interaction for a greater reduction in MACE with prasugrel in patients with ≤1 thrombotic risk factor. Conversely, there were no differences in major bleeding among patients treated with prasugrel and clopidogrel.

Conclusions

Patients with ACS at high thrombotic risk who undergo PCI are at increased risk of adverse events. Prasugrel, although mainly reserved to patients with lower burden of comorbidities, reduced the risk of ischemic events both in patients at high and low-to-moderate thrombotic risk as compared with clopidogrel.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo and Eli Lilly and Company Clinical outcomes at 1 year.Impact of number of risk factors

Guided and unguided de-escalation from potent P2Y12 inhibitors among patients with ACS: a meta-analysis

Background

Dual antiplatelet therapy (DAPT) with a potent P2Y12 inhibitor is recommended in patients with acute coronary syndrome (ACS) and should be tailored according to ischemic and bleeding risks, which are highest in the acute phase, and gradually attenuate overtime. De-escalation strategies of DAPT aim to optimize this balance of risks.

Purpose

We compared guided or unguided DAPT de-escalation strategies from potent P2Y12 inhibitors to either clopidogrel or lower doses of potent P2Y12 inhibitors versus standard DAPT with potent P2Y12 inhibitors among patients with ACS.

Methods

PubMed, Google Scholar and Cochrane Central Register of Controlled Trials were searched from inception till March 10th 2021. 1633 records were screened on DAPT de-escalation strategies after ACS for inclusion. Aspirin monotherapy and non-randomized trials were excluded.

The primary endpoint was BARC ≥2 bleeding. Other endpoints included MACE (defined according to the definitions reported in the original study protocols), all-cause death, cardiovascular death, myocardial infarction, stent thrombosis, and stroke. Hazard ratios (HRs) and 95% CIs were used as metric of choice for treatment effects with random-effects models. Heterogeneity was assessed with the I2 index. We assessed the interaction between de-escalation strategy (guided vs. unguided) and treatment with a random-effects meta-regression analysis with the empirical Bayes method. This study has been submitted to PROSPERO for registration.

Preliminary findings

Four randomised trials and a total of 8,082 patients randomly allocated to a de-escalation strategy (genetic guided to clopidogrel, n=1,242; platelet function guided to clopidogrel, n=1,304; unguided to clopidogrel (n=323); unguided to lower dose, n=1,170) or standard DAPT (n=4,043) were included in our analysis. De-escalation strategy had a reduction in BARC ≥2 bleeding (HR 0.57, 95% CI 0.37–0.89; I2=81%). MACE (HR 0.79, 95% CI 0.62–1.02; I2=0%), all-cause death (HR 0.89, 95% CI 0.58–1.36), cardiovascular death (HR 0.63, 95% CI 0.36–1.10; I2=0%), myocardial infarction (HR 0.81, 95% CI 0.56–1.17; I2=0%), stent thrombosis (HR 0.57, 95% CI 0.19–1.74; I2=0%) and stroke (HR 0.73, 95% CI 0.39–1.35; I2=0%) did not differ between patients with a de-escalation strategy and those without. Meta-regression analysis did not show any significant interaction between de-escalation method (guided vs. unguided) and treatment effects, except for BARC ≥2 bleeding (P interaction = 0.070), suggesting a greater reduction with unguided de-escalation.

Conclusion

A de-escalation strategy of DAPT after ACS was associated with a lower number of clinically relevant bleeding events, mostly in patients who underwent unguided de-escalation, while no association with increased ischemic events was found. However, the observed broad confidence intervals limit the certainty of our findings.

Funding Acknowledgement

Type of funding sources: None. BARC ≥2 bleedingMACE

Impact of left ventricular ejection fraction on clinical outcomes in females undergoing percutaneous coronary intervention with drug-eluting stents

Background

Reduced left ventricular ejection fraction (LVEF) is associated with increased risk of adverse events among patients undergoing percutaneous coronary intervention (PCI). Due to under-enrollment of females in randomized trials, there is limited data on the impact of LVEF on post-PCI outcomes in female patients.

Purpose

To evaluate the impact of varying degrees of LVEF impairment on 3-year outcomes in female patients undergoing PCI with drug-eluting stents (DES).

Methods

We pooled patient-level data of female patients from 26 randomized trials of coronary stents. The study population was stratified into three groups according to the 2016 European Society of Cardiology Heart Failure guidelines: LVEF ≥50% (normal), LVEF 40–49% (mid-range), and LVEF <40% (reduced). The primary outcome was major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), or stent thrombosis (ST) at 3-year follow-up. The Kaplan-Meier method was used for time-to-event analyses, with comparative risks being assessed using Cox regression.

Results

Out of 5672 female patients with available LVEF values at baseline, 4427 (78.1%) had normal LVEF, 602 (10.6%) had mid-range LVEF, and 643 (11.3%) had reduced LVEF. Patients with reduced LVEF were older and had a higher prevalence of smoking, prior MI, and multi-vessel disease. There was a stepwise increase in 3-year event rates moving from normal, to mid-range and reduced LVEF (Figure 1). After multivariable adjustment, hazard ratio (HR) for MACE was 1.45 (95% CI: 1.10–1.92) in patients with mid-range LVEF and 2.43 (95% CI: 1.84–3.22) in patients with reduced LVEF (trend p-value <0.0001). The risk of ST was more than doubled in both mid-range LVEF (HR 2.30, 95% CI: 1.30–4.06, p=0.004) and reduced LVEF patients (HR 2.18, 95% CI: 1.11–4.28, p=0.02), as compared with normal LVEF.

Conclusion

The presence of an even mild degree of LVEF impairment confers an increased risk of ischemic events, including ST, among females undergoing PCI with DES.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Ticagrelor monotherapy after percutaneous coronary intervention in patients with concomitant diabetes mellitus and chronic kidney disease: a TWILIGHT substudy

Background

Diabetes mellitus (DM) and chronic kidney disease (CKD) are established risk factors for cardiovascular events, with patients presenting both conditions being at extremely high risk. P2Y12 inhibitor monotherapy with ticagrelor after a short course of dual antiplatelet therapy has emerged as a bleeding avoidance strategy for high-risk patients undergoing percutaneous coronary intervention (PCI).

Purpose

To investigate ischemic and bleeding outcomes associated with ticagrelor monotherapy versus ticagrelor plus aspirin according to the presence or absence of CKD and DM.

Methods

The TWILIGHT trial enrolled patients undergoing PCI with a drug-eluting stent who fulfilled at least one clinical and one angiographic high-risk criterion. Both DM and CKD (estimated glomerular filtration rate <60 mL/min/1.73m2) were clinical study entry criteria. Following 3 months of ticagrelor plus aspirin, patients who had been adherent to treatment and free from major adverse events were randomly assigned to either aspirin or placebo in addition to ticagrelor for 1 year. The primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding. The key secondary endpoint was the composite of all-cause death, myocardial infarction, or stroke. Net adverse clinical events (NACE) were defined as BARC type 3 or 5 bleeding, all-cause death, myocardial infarction, or stroke.

Results

Of the 6273 patients included in the analysis, 8.0% had both CKD and DM (DM+/CKD+), 8.9% had CKD only (DM-/CKD+), 29.0% had DM only (DM+/CKD-), and 52.1% had neither CKD nor DM (DM-/CKD-). At 1-year follow-up, there was a progressive increase in the rates of bleeding and ischemic events according to DM and CKD status (Figure 1). Ticagrelor plus placebo reduced the primary bleeding endpoint as compared with ticagrelor plus aspirin across all study groups, including DM+/CKD+ patients (4.7% vs. 8.7%; HR 0.52, 95% CI 0.25–1.07), with no evidence of heterogeneity (p-interaction=0.68). Similar treatment effects of ticagrelor monotherapy were observed for major BARC type 3 or 5 bleeding (p-interaction=0.17), with DM+/CKD+ patients showing the greatest absolute risk reduction (0.9% vs. 5.1%; HR 0.16, 95% CI 0.04–0.72). The key secondary endpoint was not significantly different between treatment arms across study groups, with the exception of a reduced risk in DM+/CKD- patients receiving ticagrelor monotherapy (p-interaction=0.033). A similar pattern in the DM+/CKD- group was observed for NACE (p-interaction=0.030) (Figure 2).

Conclusions

Among high-risk patients undergoing PCI, ticagrelor monotherapy reduced the risk of clinically relevant and major bleeding without a significant increase in ischemic events as compared with ticagrelor plus aspirin, irrespective of the presence of DM and CKD. Furthermore, ticagrelor monotherapy seemed to be associated with a more favourable net benefit in patients with DM without CKD.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Investigator-initiated grant from AstraZeneca Figure 1. Event rates according to DM/CKD statusFigure 2. Effects of ticagrelor monotherapy

A genome-wide association study identifies novel genetic loci associated with pulmonary embolism

Background

Pulmonary embolism (PE) is a life-threatening cardiovascular condition. Studies showed that PE patients were associated with disorders of lipid metabolism and had higher triglyceride and lower HDL-C levels compared with healthy. We conducted the genome-wide association study to identify novel loci contributing to PE.

Methods

We conducted a large-scale GWAS of PE in 5,466 PE cases and 461,219 controls of European ancestry from the UK Biobank (466,685 participants total). We used genome-wide summary statistics to test for enrichment of functional annotations using ENRICHR. Example pathways included in Enrichr for testing include membership of genes in pathway databases such as the Kyoto Encyclopedia of Genes and Genomes (KEGG), Wikipathway, PANTHER, BioCarta or NCI-Nature pathways. We analyzed the pathways using combined score and p-values which were well validated by comparing to several methods. For pathway analyses, we considered a nominal P-value threshold of 0.05.

Results

We identified genome-wide significant genetic associations in 63 independent genetic loci for PE (P<5.0x10–7). Our findings for top pathways highlight that lipid metabolism (LIPC, LCAT, NPC2), caffeine metabolism (NAT2), and sudden cardiac death (ABCG8) related genetic loci play an important role in PE alongside genes already associated with coagulation-thrombosis pathway (VWF, THPO, PTPN11, INPP5D, UROS, HMBS) (all p-values p-values <0.05).

Conclusion

Our findings uncovered unexpected novel factors of PE etiology, suggesting novel mechanistic concepts of PE pathophysiology.

Funding Acknowledgement

Type of funding source: None

Intersection of the Academic Research Consortium – high bleeding risk criteria in patients undergoing PCI for acute coronary syndromes: insights from a high-volume single centre registry

Introduction

Patients presenting for percutaneous coronary intervention (PCI) with acute coronary syndromes (ACS) often have overlapping bleeding and ischaemic risk factors that offset the long-term success of PCI and limit the post stenting therapeutic options. Aiming at improving outcomes following PCI, the Academic Research Consortium (ARC) recently published a set of major and minor criteria that identify, a priori, patients at high bleeding risk (HBR). Indeed, knowledge of these risk factors will help in optimization of pre-procedural therapy and minimization of post intervention complications. Nonetheless, the actual prevalence of these criteria among patients undergoing PCI for ACS is not well known.

Purpose

To determine the intersection and distribution of ARC-HBR major and minor criteria in a real-world ACS population presenting for PCI.

Methods

In this analysis, we included all patients who presented with ACS to a high-volume PCI centre from 2012 to 2017 and underwent PCI with 2nd generation drug-eluting stent (DES) implantation. Patients were then classified as HBR if they met ≥1 major or ≥2 minor criteria according to the ARC-HBR definition. Baseline clinical and procedural characteristics were extracted from each patient electronic health records. The most common exclusive intersections of ARC-HBR major and minor criteria were quantitatively visualized using an Upset Plot.

Results

Only 44.6% (n=2,717) of ACS patients (n=6,097) fulfilled the ARC-HBR definition. There were significant differences in baseline clinical characteristics between HBR and non-HBR groups: age (71.4±11.5 vs. 60.9±10.3 years, p<0.001), females (40.7% vs. 25.5%, p<0.001), cerebrovascular disease (19.5% vs. 3.9%, p<0.001), and diabetes (55.4% vs. 42.1%, p<0.001). The prevalence of active smoking, a major risk factor for bleeding, was higher in the non-HBR group (20.6% vs. 9.9%, p<0.001). The most frequent major and minor criteria were severe anemia (n=1,072) and age ≥75 (n=1,264), respectively. The top five criteria intersections were: severe anemia (n=215), age ≥75 and moderate chronic kidney disease (CKD) (n=145); moderate CKD and mild anemia (n=142); age ≥75 and mild anemia (n=140); age ≥75, moderate CKD, and mild anemia (n=130) (Figure 1).

Conclusion

Among patients who have undergone PCI for ACS, a significant proportion of individuals fulfilled the ARC-HBR definition. Severe anemia was the most prevalent major criteria. Different combinations of minor criteria, mainly age ≥75, moderate CKD and mild anemia, represented the most common intersections.

Figure 1

Funding Acknowledgement

Type of funding source: None

Side branch FFR after provisional stenting: simplified approach based on OCT frame count

Background/Introduction

Treatment of bifurcation coronary artery lesions remains a major challenge in interventional cardiology. Side branch (SB) stenoses are frequently observed after stent implantation in bifurcation lesions, although angiographically narrowed SBs may not be functionally significant. Fractional flow reserve (FFR), a pressure-derived index of the hemodynamic significance of a coronary artery stenosis, may be useful in determining whether additional intervention is required in jailed SBs. Angiography and intravascular ultrasound (IVUS) derived parameters have showed poor diagnostic accuracy in predicting the functional significance of jailed SBs.

Purpose

The aim of the present study was to use high resolution optical coherence tomography (OCT) imaging to predict functionally significant SB stenoses after provisional stenting defined as SB FFR ≤0.80.

Methods

Seventy-one patients with 71 calcified bifurcation lesions with angiographically intermediate SB stenoses undergoing provisional stenting were enrolled in the prospective study. OCT pullbacks were performed before and after stent placement, and SB FFR was measured after main vessel stenting. SB ostium area (SBOA) was assessed using three-dimensional OCT cut-plane analysis off-line. In addition, we developed a simplified approach to SB ostium assessment based on SB ostium frame count using two-dimensional OCT pullback not requiring off-line 3D reconstruction. For the analysis, consecutive frames were counted between the most distal and most proximal take-off of the SB frames.

Results

Similar to previous studies, quantitative coronary angiography findings were not associated with the functional significance of SBs after main vessel stenting. In contrast, SBOA assessed by 3D-OCT after provisional stenting strongly correlated with post-procedure SB FFR. The optimal cut-off value for the SBOA area to predict a SB FFR ≤0.80 was 0.76 mm2 (sensitivity 82%, specificity 89% and area under the curve of 0.92 (95% CI: 0.84–0.99). A simplified approach to SB ostium assessment using OCT frame count yielded a sensitivity of 82%, specificity 89% and area under the curve 0.92 (95% CI: 0.84 to 0.99) with a cut-off of 4.5 frames allowing detection of functionally significant SB stenoses during the procedure in real time. Figure 1 shows a receiver-operating characteristic curve for SB FFR ≤0.8 and a representative case with SB FFR = 0.66 after provisional stenting and SB ostium frame count equal 3 (Frame 1 to 3)

Conclusion(s)

Assessment of SB using either 3D OCT off-line reconstruction or a simplified approach based on OCT frame count can detect SB branches with FFR ≤0.80 with high sensitivity and specificity. The developed approaches may represent a useful tool to assess provisional stent outcomes.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific; St. Jude Medical

Are the minor high bleeding risk criteria of the academic research consortium truly minor? Insights from a high-volume tertiary care pci centre

Background

The Academic Research Consortium (ARC) has recently published a consensus-based definition to identify patients at high bleeding risk (HBR), reflected by a BARC 3 or 5 bleeding rate of ≥4% at 1 year after percutaneous coronary intervention (PCI). The HBR criteria included in the definition are divided into minor and major categories, with patients deemed to be at HBR if they fulfill at least one major or two minor criteria. As a result, patients who present with only one minor criterion are categorized as non-HBR.

Purpose

To compare the differences in baseline characteristics and 1-year bleeding and ischaemic outcomes between non-HBR patients undergoing PCI that present with only one minor HBR criterion versus those that do not fulfill any HBR criteria.

Methods

The study population consisted of all consecutive patients who underwent PCI with stent implantation in a single high-volume centre from January 2014 to December 2017. Patients were classified as non-HBR if they did not fulfill at least one major or two minor ARC-HBR criteria. The outcomes of interest were major bleeding (composite of peri-procedural and post-discharge bleeding), all-cause death, and myocardial infarction (MI) at 1 year. The Kaplan-Meier method was used for time-to-event analyses, with comparative risks being assessed using Cox regression.

Results

Of the 9,623 patients included in the analysis, 5,345 were classified as non-HBR. Within the non-HBR patients, 2,078 (38.9%) presented with only one minor HBR criterion and 3,267 (61.1%) presented with no HBR criteria. Non-HBR patients with one minor criterion were more often female, significantly older, with a higher burden of comorbidities such as diabetes mellitus, hypertension and hyperlipidaemia, and more likely to have multivessel disease as well as a history of prior MI and revascularisation, while non-HBR patients with no criteria were more likely to be smokers and have a higher BMI. Distribution of the minor HBR criteria within the group presenting with one minor criterion are illustrated in the figure. Non-HBR patients with only one minor criterion had a numerically higher rate of major bleeding compared to non-HBR patients with no criteria (3.6% vs. 2.9%, p=0.09). While the rate of all-cause death was significantly higher in the group with only one minor criterion (1.2% vs. 0.4%, p=0.004), there was no difference in the rate of MI between the two groups (2.1% vs. 1.9%, p=0.83). Hazard ratios comparing the two groups are presented in the figure.

Conclusions

Non-HBR patients presenting with only one minor criterion had a numerically higher rate of post-PCI bleeding and significantly higher mortality compared to those without any criteria. Nonetheless, the major bleeding rates of both groups at 1 year were less than the 4% cutoff to qualify as HBR according to the ARC definition, thereby supporting their inclusion as “minor” criteria in the recent ARC-HBR definition.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of high-density lipoprotein levels in males and females undergoing percutaneous coronary intervention with drug eluting stents

Background/Introduction

Low levels of high-density lipoprotein (HDL) have been associated with adverse cardiovascular events in multiple epidemiological studies. Evidence regarding the role of HDL in males and females with established coronary artery disease undergoing percutaneous coronary intervention (PCI) with drug eluting stents (DES) is scarce.

Purpose

We sought to investigate the impact of low HDL levels on 1-year cardiovascular outcomes in males and females undergoing PCI with DES.

Methods

We screened all patients undergoing PCI in our center from 2012 to 2017. Exclusion criteria were: unavailable baseline HDL measurement, age <18 years, presentation with ST-segment elevation myocardial infarction (MI) or shock, coexisting neoplastic disease and treatment without a stent or with a bare metal stent. The final population was divided by gender and further stratified to the high or low HDL group according to baseline HDL levels. Cut-offs were 40mg/dL in males and 50mg/dL in females, per the most recent ACC/AHA guideline recommendations. The primary endpoint of the analysis was major adverse cardiovascular events (MACE) at 1 year, defined as death, MI or target vessel revascularization (TVR). To account for potential clinical and anatomical confounders the outcomes were also adjusted for age, Caucasian ethnicity, hypertension, diabetes mellitus (DM), body mass index, smoking, prior MI, multi-vessel disease and type B2/C lesions.

Results

Out of the 10,843 patients included, 7,718 (71.2%) were male and 3,125 (28.8%) were female. Low HDL was noted in 58.5% of males and 63.8% of females. Patients with low HDL were younger and had a higher prevalence of DM, prior MI, smoking and multi-vessel disease. When comparing low to high HDL groups in terms of 1-year MACE a borderline significant difference was shown in males (7.4% vs. 6.0%; p-value=0.08) but not in females (7.7% vs 8.1%; p-value=0.90) [Panel A]. The numerically higher incidence of MACE in males with low HDL was primarily driven by TVR (5.4% vs 3.7%; p-value=0.005) while the rates of Death (1.4% vs. 1.3%; p=0.96) and MI (2.0% vs. 1.8%; p-value=0.89) were similar between the two groups. After adjustment the male low HDL subgroup remained at a higher risk for 1-year TVR but not 1-year MACE compared to the male high HDL subgroup [Panel B]. No difference for any individual component of MACE was shown between low and high HDL subgroups in females [Panel C].

Conclusion(s)

High HDL levels were associated with a lower incidence of TVR and borderline reduction of MACE in male but not female patients undergoing PCI with DES. No difference was demonstrated in terms of death or MI between the high and low HDL subgroups at 1-year follow-up.

Impact of HDL levels according to gender

Funding Acknowledgement

Type of funding source: None

Long-term outcomes in high-bleeding risk patients undergoing PCI for acute coronary syndromes: results from a large single-center pci registry

Introduction

Current clinical guidelines recommend prolonged dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndromes (ACS). However, an extended DAPT duration in high-bleeding risk (HBR) patients amplifies the risk of post procedural complications. Hence, clinicians often face the dilemma of prolonging DAPT duration to prevent recurrent ischaemic events at the expense of increasing the incidence of bleeding in high-risk patients. The actual incidence of ischaemic and bleeding events in this particular population is not well elucidated.

Purpose

To evaluate one-year ischemic and bleeding outcomes following PCI for ACS in a real-world HBR population as defined by the Academic Research Consortium (ARC) consensus document.

Methods

We included all patients who presented with ACS to a high-volume single PCI centre from 2012 to 2017 and underwent PCI with 2nd generation drug-eluting stent implantation. Patients were classified as HBR if they met ≥1 major or ≥2 minor criteria according to the recent ARC-HBR consensus. The outcomes of interest were major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI), and target lesion revascularization (TLR), and major bleeding events, including both peri-procedural and post-discharge bleeding. All outcomes were assessed at 1-year follow-up. The Kaplan-Meier method was used for time-to-event analyses.

Results

Out of 6,097 ACS patients included in this analysis, 2,717 (44.6%) fulfilled the ARC-HBR definition. Compared to non-HBR group, HBR patients were more frequently female, older, more likely to have cardiovascular risk factors (e.g., diabetes, hypertension, and hyperlipidemia) and complex coronary artery disease (e.g., multi-vessel disease, bifurcation lesions, and calcification). The 1-year incidence of MACE was significantly higher in HBR patients (16.3% vs. 8.1%, HR 2.16, 95% CI [1.81–2.59], p<0.001) (Figure 1A). This finding was driven by higher rates of all-cause death and MI (Figure 1B). The 1-year incidence of major bleeding was also significantly higher in HBR patients compared to non-HBR (11.1% vs. 3.1%, HR: 3.92, 95% CI 3.10–4.95; p<0.001).

Conclusions

HBR patients undergoing PCI for ACS are not only subject to bleeding complications but are also at an increased risk for ischemic events and all-cause mortality.

Figure 1

Funding Acknowledgement

Type of funding source: None

P6138Quality of clinical trial evidence on devices and drugs approved to treat coronary artery disease

Background

Regulatory approval of drugs and devices follow two different pathways. Whether different approval pathways underlie meaningful differences in quality of clinical trial evidence is unknown. We aimed to compare the quality of evidence of clinical trials that served as a basis for approval by the U.S. Food and Drug Administration (FDA) of drugs and devices used for the treatment of coronary artery disease.

Methods

FDA databases were searched for devices (i.e., coronary artery drug-eluting stents) and drugs (i.e., agents targeting atherothrombosis) approved between January 1st, 2001 and December 31st, 2017. FDA medical reviews were screened to identify trials that served for approval purposes. The pre-specified primary outcome was the prevalence of randomized trials used for approval (i.e. number of randomized trials/overall number of trials).

Results

A total of 97 trials were identified, 39 serving for approval of 13 devices and 58 serving for approval of 8 drugs. Devices were evaluated by fewer trials per item as compared with drugs (3.0±1.4 vs. 7.3±5.3, P=0.012) with similar study size (501 [100–1314] vs. 379 [183–904] patients per trial, P=0.55). Trials evaluating devices were less frequently randomized (56.4% vs. 94.8%, P<0.001) and more frequently designed powered for clinical endpoints (53.8% vs. 17.2%, P<0.001) as compared to those evaluating drugs. Use of randomization declined over time among trials supporting FDA approval of devices. In addition, significant differences were present between trials evaluating devices and those evaluating drugs in terms of study design, comparator used, blinding to treatment allocation, primary hypothesis, primary endpoint, and type of patients included.

Use of randomized trials for approval

Conclusions

There are substantial differences in clinical trial evidence serving for FDA approval of devices and drugs used for treatment of coronary artery disease. The lower degree of randomized evidence used for approval of devices as compared to drugs raises some concerns, particularly in view of its decline over time.

P1760Incidence and effects of stroke, MI and bleeding on mortality among patients with ACS undergoing PCI: a comparative analysis from the PROMETHEUS registry

Background

Stroke represents a potentially calamitous complication among patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) even though its rates are relatively low. Data on the distribution of stroke occurrence over time and its overlap with myocardial infarction (MI) and bleeding after PCI is scarce.

Purpose

We sought to compare the occurrence and impacts of stroke, MI and bleeding on subsequent mortality in ACS patients undergoing PCI in contemporary clinical practice.

Methods

A total of 19,914 ACS patients who underwent PCI in the PROMETHEUS multi-center observational study were analyzed. We calculated the cumulative stroke incidence at 30 days and 1 year using Kaplan Meier (KM) method. We also compared the distribution of stroke, myocardial infarction (MI) and bleeding across time and evaluated the overlap between their occurrences. Predictors of 1 year stroke occurrence were identified through multivariable Cox-regression and stroke, MI and bleeding were entered as time-updated covariates to estimate their individual effects on subsequent mortality.

Results

Of the total number of patients, 244 patients (1.5%) had a stroke within 1 year. 48 of these patients also experienced an MI while another 48 patients experienced a bleeding event. Furthermore, 14 of these overlapping patients experienced a stroke, MI and bleeding event, all within the 1-year follow-up. Patients who sustained a stroke were more likely to have a prior history of cerebrovascular disease, peripheral artery disease, MI and heart failure compared to those who did not have a stroke. Mortality risk was significantly higher among those with stroke versus those without stroke (adjusted HR 4.84, p<0.0001). However, the association attenuated over time with a much larger effect in the first 30 days of its occurrence (adjusted HR 17.7, p<0.0001) versus beyond 30 days (adjusted HR 1.22; 95% CI: 0.6–2.46, p=0.58). Although the effects of MI and bleeding on subsequent mortality within 30 days of occurrence were significantly lower than stroke (adjusted HR 6.22, p<0.0001; adjusted HR 7.30, p<0.0001, respectively), their effects were more sustained on mortality beyond 30 days (adjusted HR 2.89, p<0.0001; adjusted HR 3.05, p<0.0001, respectively).

Conclusion

When compared with MI and bleeding, stroke had a substantially stronger impact on mortality that attenuated rapidly over time among ACS patients undergoing PCI. Optimization of modifiable risk factors and medication adherence are essential parts of management of stroke following PCI for ACS.

Exome sequencing of extreme clopidogrel response phenotypes identifies B4GALT2 as a determinant of on-treatment platelet reactivity

Interindividual variability in platelet aggregation is common among patients treated with clopidogrel and both high on-treatment platelet reactivity (HTPR) and low on-treatment platelet reactivity (LTPR) increase risks for adverse clinical outcomes. CYP2C19 influences clopidogrel response but only accounts for ∼12% of the variability in platelet reactivity. To identify novel variants implicated in on-treatment platelet reactivity, patients with coronary artery disease (CAD) with extreme pharmacodynamic responses to clopidogrel and wild-type CYP2C19 were subjected to exome sequencing. Candidate variants that clustered in the LTPR subgroup subsequently were genotyped across the discovery cohort (n = 636). Importantly, carriers of B4GALT2 c.909C>T had lower on-treatment P2Y12 reaction units (PRUs; P = 0.0077) and residual platelet aggregation (P = 0.0008) compared with noncarriers, which remained significant after adjusting for CYP2C19 and other clinical variables in both the discovery (P = 0.0298) and replication (n = 160; PRU: P = 0.0001) cohorts. B4GALT2 is a platelet-expressed galactosyltransferase, indicating that B4GALT2 c.909C>T may influence clopidogrel sensitivity through atypical cell-surface glycoprotein processing and platelet adhesion.

Current developments in dual antiplatelet therapy after stenting

Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and an inhibitor of the adenosine diphosphate platelet receptor P2Y12 has been shown to reduce the risk of stent thrombosis (ST), myocardial infarction and cardiac death after percutaneous coronary intervention (PCI) with bare-metal stents (BMS) and drug-eluting stents (DES). However, while there is consensus on 1-month DAPT after BMS, the optimal duration and the risk-benefit ratio of DAPT duration after DES implantation remains controversial. Controversy surrounding this issue is demonstrated by differences in guideline recommendations for DAPT duration after PCI with DES. For example, while the ACC/AHA recommends a minimum of 12 months, ESC guidelines recommend at least 6 months of DAPT. Recent reports suggest that 6 months of DAPT after second-generation DES implantation might be safe compared with longer durations. Large randomized controlled trials powered to examine ST and bleeding events are currently ongoing and will shed novel insight on unresolved concerns and inform medical practice in the foreseeable future. In the present review, we critically and comprehensively examine the current level of evidence regarding the optimal duration of DAPT after PCI with DES and illustrate new and future perspectives surrounding this rapidly changing field.

Immunization of mice with human 60-kd Ro peptides results in epitope spreading if the peptides are highly homologous between human and mouse

OBJECTIVE

Immunization with peptide fragments of autoantigens may lead to an immune response at both the T and B cell level that is directed not only at the immunogen, but also at the autoantigen from which the peptide came. In addition, a complex multicomponent particle may become the target of this expanded immune response. The purpose of this study was to determine the ability of several different peptides from 60-kd Ro to induce expansion of the immune response to the Ro/La RNP particle.

METHODS

We immunized BALB/c mice with 3 different oligopeptides from human 60-kd Ro (or, SSA).

RESULTS

Animals immunized with peptides either identical to or differing by only 1 amino acid developed autoimmunity to the entire Ro RNP particle. Animals immunized with a human peptide highly divergent from the corresponding mouse sequence developed an immune response to the immunogen only and showed little evidence of epitope spreading. Furthermore, these mice did not have antibodies that bound the poorly conserved mouse homolog peptide, and the antibody response to this peptide did not include IgG1.

CONCLUSION

These data indicate that B lymphocytes specific for the self-peptide that is homologous to the immunogen are a critical determinant for spreading of the immune response to other components of self.