Associations between DAPT score and long-term mortality post PCI

Introduction

The dual antiplatelet therapy (DAPT) score was developed to identify patients more likely to derive benefit (score ≥2) or harm (score <2) from DAPT beyond 1-year post PCI. There is no study which looked at the DAPT score and long term outcomes post PCI in Australia.

Purpose

We sought to examine long-term mortality after PCI by the DAPT score in patients treated with DAPT per local guidelines.

Methods

We examined data from the MIG PCI database from 2005 to 2018 in whom the DAPT score could be derived and grouped them as score ≥2 or <2. Long-term mortality was assessed from National Death Index linkage. The primary endpoint was long-term mortality examined using survival analysis. Secondary endpoints included 30-day ischaemic outcomes and in-hospital major bleeding.

Results

Out of 27,740 patients in the study, 9,401 (33.9%) had DAPT score ≥2. They were younger and included more females and higher prevalence of renal impairment. DAPT score ≥2 patients had higher in-hospital major bleeding, 30-day mortality, MI and target vessel revascularisation. DAPT score ≥2 patients had lower long-term survival to 12 years (p<0.001 for all).

Conclusion

A third of all-comer PCI patients had DAPT score ≥2 with greater short-term risk of ischaemic and bleeding outcomes, as well as long-term mortality. Theoretically, those with DAPT score ≥2 would benefit from longer duration of DAPT as ischaemic risk outweighs bleeding risk. However, given our finding of increased short-term bleeding risk and long-term mortality, dynamic bleeding risk assessment should be undertaken to guide pharmacotherapy strategies.

Funding Acknowledgement

Type of funding sources: None.

Outcomes after percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (cabg)

Background

In patients with prior CABG requiring subsequent PCI there is uncertainty whether bypass grafts or native coronary arteries should be targeted.

Methods

We analysed data from 2,764 patients with prior CABG in the Melbourne Interventional Group registry (2005–2018), divided into two groups: those undergoing PCI to a native vessel (n=1,928) and those with PCI to a graft vessel (n=836).

Results

Patients with a graft vessel PCI were older, had more high-risk clinical characteristics (prior MI, heart failure, ejection fraction <50%, renal impairment, peripheral and cerebrovascular disease), and high-risk procedural features (ACC/AHA types B2/C lesions). However, patients in the native vessel group were more likely to have PCI to a chronic total occlusion. The majority of graft PCI were to saphenous vein grafts (84%), with 10% to radial and 6% to LIMA/RIMA grafts. Distal embolic protection devices were used in 30% of graft PCI. Patients with graft PCI had higher rates of no reflow (6.3% vs. 1.5%; p<0.001), coronary perforation (p=0.016) and inpatient stent thrombosis (p=0.028). However, 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCE) were similar. Unadjusted long-term mortality (median follow up 4.8 years) was higher in patients who had undergone a graft PCI (44% vs. 32%, p<0.001), but following Cox proportional hazards modelling, PCI vessel type was not a predictor of long-term mortality (HR 1.13; 95% CI 0.96–1.33, p=0.14).

Conclusions

Early clinical outcomes and risk-adjusted long-term mortality are similar for patients with prior CABG undergoing PCI to a native vessel or a bypass graft.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The Alfred Hospital

Trends and Burden of Hepatitis B Viral Infection in Children and Adults in a Tertiary Health Facility in North East Nigeria Over a Fifteen-year Period

Background

Hepatitis B infection is endemic in Nigeria where greater than six percent of the general population are chronic carriers. Transmission predominantly occurs in infants and children when compared with adults. Viral hepatitis deaths are mostly due to chronic liver disease. Routine immunization against hepatitis B virus infection in Nigeria is still low.

Aims

We planned to describe the burden and trend of hepatitis B viral infection at Federal Teaching Hospital, Gombe.

Methodology

This study was a retrospective cross-sectional descriptive study. The results of all hepatitis B surface antigen (HBsAg) tests using rapid chromatographic immunoassay performed at the Federal Teaching Hospital, Gombe (FTHG), Nigeria from January 2000 to December 2014 were retrieved and analyzed.

Results

Between 2000 and 2014, 23,611 individuals ranging from 2 months to 98 years of age were tested for HBsAg. A total of 13,136 (55.6%) were males and 10,475 (44.4%) were females. Among individuals tested for hepatitis B surface antigen, 18.9% (4,456) were positive. A total of 70.6% (3,147) were males and 29.4% (11,239) were females. Male sex was significantly associated with HBsAg positivity (P < 0.001). The mean HBsAg prevalence over the 15-year periods among males and females were 22% and 12%, respectively (P < 0.001). The mean yearly HBV prevalence was 17.5%, 17.2%, 19.6%, 15.5%, and 4.4% among age-groups 0-18 years, 19-25 years, 26-45 years, 56-65 years, and >65 years, respectively (P = 0.132). The proportion of HBsAg-positive individuals was highest in the year 2012 (28.7%) and lowest in 2014 (1.8%).

Conclusion

There was an increasing trend in HBV testing and diagnosis in children and adults in our facility over the last 15 years. Health facility capacity for HBV treatment and care requires strengthening.

P5290Impact of extreme obesity on long-term outcomes following percutaneous coronary intervention

Background

Obesity is a growing health concern worldwide, particularly in developed countries where there has been an unprecedented rise in the proportion of overweight and obese individuals in the population. Previous studies have reported a protective effect of obesity compared to normal BMI in patients undergoing percutaneous coronary intervention (PCI). However, it is unclear whether this effect extends to the extremely obese over long-term follow-up.

Objective

To determine whether an obesity paradox persists in contemporary PCI practice over long-term follow-up, and in particular to further evaluate the association between extreme obesity and long-term clinical outcomes after PCI.

Method

We prospectively collected data on 25,645 patients undergoing PCI between 1 January 2005 and 30 June 2017 who were enrolled in the statewide multi-centre Melbourne Interventional Group Registry. This registry collects data on all patients undergoing PCI at 6 academic tertiary hospitals. Patients were stratified by World Health Organization-defined BMI categories. Long-term mortality data was obtained by linkage to the National Death Index (NDI), a database that contains records of all deaths occurring in Australia. The primary endpoint was NDI-linked mortality. Median length of follow-up was 4.4 years (IQR 2.0–7.6 years).

Results

Of the study cohort, 24.6% had normal BMI (18.5–24.9 kg/m2), 0.9% were underweight (BMI <18.5 kg/m2) and 3.3% were extremely obese (BMI ≥40 kg/m2). As BMI increased, mean age decreased while the prevalence of diabetes increased (p<0.001). The proportion of females at both extremes of BMI. Procedural characteristics were similar across the groups although there was more radial access and less femoral access used with increasing BMI (p<0.001). In terms of secondary prevention therapy, underweight patients were significantly less likely to receive a beta blocker, ACE inhibitor and statins, compared to the other BMI groups. In-hospital, 30-day and long-term mortality were all highest for underweight patients (37.7%) and lowest for the moderately obese patients (BMI 35–40 kg/m2) (12.2%). After adjustment for age, comorbidities and presentation with cardiogenic shock, a U-shaped association between the different BMI categories and adjusted hazard ratio for long-term mortality was observed (Figure 1).

Figure 1

Conclusion

An obesity paradox is still apparent in contemporary practice with elevated BMI up to 35 kg/m2 associated with reduced long-term mortality after PCI. However, this protective effect appears not to extend to patients with extreme obesity. Factors behind this phenomenon are likely multifactorial and require further mechanistic and epidemiological studies.