Bleeding, ischemic risk increased in high-risk patients after PCI
Patients who underwent PCI and had high-risk features according to European Society of Cardiology guidelines were more likely to have bleeding and ischemic events compared with those without high-risk features, according to a study published in JACC: Cardiovascular Interventions.
PCI in Swiss patients
Yasushi Ueki, MD, of the department of cardiology at Bern University Hospital in Switzerland, and colleagues analyzed data from 10,236 patients who underwent PCI in Switzerland between 2009 and 2015. Follow-up was conducted for 1 year for MI, death, revascularization, stroke, bleeding complications, stent thrombosis, medical treatment and rehospitalization. All patients completed a health questionnaire during follow-up to collect information on adverse events and rehospitalization.
The primary ischemic endpoint was a device-oriented composite endpoint, which was defined as a composite of target vessel MI, cardiac death and target lesion revascularization. The primary bleeding endpoint was Bleeding Academic Research Consortium (BARC) types 3 to 5. Secondary endpoints included cardiac death, all-cause death, target vessel MI, any MI, TLR, any repeat revascularization, definite or probable stent thrombosis, non-TVR, BARC types 3 to 5 and any bleeding.
Guideline-endorsed high-risk features were defined as chronic kidney disease, diffuse multivessel disease in patients with diabetes, bifurcation with two stent implants, at least three treated lesions, treatment of chronic total occlusion and total stent length greater than 60 mm per lesion.
Of patients in the study, 52% had at least one high-risk feature. Patients with high-risk features were more likely to have BARC types 3 to 5 (4.9% vs. 2.2%; P < .001) and the device-oriented composite endpoint (12.3% vs. 5.5%; P < .001) compared with those without high-risk features.
Increased risk for events
There was a gradual increase for BARC types 3 to 5 in patients with zero (2.2%), one to two (4.5%) and at least three high-risk features (6.6%; P < .001). This was also seen for the device-oriented composite endpoint (5.5%, 11.3% and 16.7%, respectively; P < .001).
Compared with patients with a PRECISE DAPT score less than 25, those with a score greater than 25 had a consistently higher incidence of the device-oriented composite endpoint, definite or probable stent thrombosis, cardiac death and BARC types 3 to 5.
“Although further studies are required to ascertain the appropriate [dual antiplatelet therapy] regimen among patients with both high ischemic and bleeding risk, physicians should pay more effort to mitigate modifiable ischemic and bleeding risk factors to improve outcomes in this dilemmatic cohort,” Ueki and colleagues wrote.
“Based on these findings, in line with the ‘primum non nocere’ principle, [high bleeding risk] status should probably take priority when evaluating the candidacy of an individual patient for extended DAPT,” Gennaro Giustino, MD, cardiology fellow at The Icahn School of Medicine at Mount Sinai, and Francesco Costa, MD, PhD, interventional cardiologist at University of Messina in Italy, wrote in a related editorial. “Therefore, patients at [high bleeding risk] should be treated with the shortest duration possible of DAPT, irrespective of the underlying ischemic risk, as the occurrence of a major bleeding in patients at [high ischemic risk] may have major consequences.” – by Darlene Dobkowski
Disclosures: Ueki, Giustino and Costa report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.