Post-Discharge Bleeding and Mortality Following Acute Coronary Syndromes With or Without PCI

The Association Between Peripheral Arterial Disease and Long-Term Bleeding Events in Patients with Acute Myocardial Infarction

Background: Peripheral arterial disease (PAD) is associated with cardiovascular events in patients with acute myocardial infarction (AMI). However, there are limited reports regarding the association between PAD and bleeding events. In this study, we aimed to evaluate whether PAD is independently associated with an increased risk of major bleeding events, in addition to major adverse cardiovascular events (MACEs), in patients with AMI undergoing percutaneous coronary intervention (PCI). Methods: We included 1391 patients with AMI who underwent PCI and divided them into the PAD group (n = 210) and the non-PAD group (n = 1181). The primary endpoint was total bleeding events, defined as Bleeding Academic Research Consortium type 3/5. The secondary endpoint was MACE, defined as the composite of all-cause death, non-fatal myocardial infarction, and hospitalization for heart failure. Results: The median follow-up duration was 653 days. Total bleeding events were more frequently observed in the PAD group than in the non-PAD group (24.8% vs. 11.3%, p < 0.001). The multivariate Cox hazard analysis confirmed that PAD was significantly associated with total bleeding events (HR 1.509; 95% CI 1.056-2.156, p = 0.024) as well as MACEs (HR 2.152; 95% CI 1.510-3.066, p < 0.001) after controlling for confounding factors. Conclusions: PAD was independently associated with a higher risk of major bleeding and cardiovascular events in patients with AMI undergoing PCI. These findings suggest that PAD should be recognized as a critical factor in risk stratification for AMI and may affect individualized bleeding risk management strategies in patients with AMI.

Safety of crushed/chewed P2Y12 inhibitors in acute coronary syndromes - a meta-analysis of randomized controlled trials

The administration of crushed or chewed P2Y12 inhibitors (P2Y12i) allows faster platelet inhibition in patients presenting acute coronary syndrome (ACS). Whether this administration approach is safe needs further analysis. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing chewed/crushed to integral P2Y12i administration in patients with ACS. Major bleeding, minor bleeding, and major adverse cardiovascular events (MACE) were analyzed as binary outcomes. Platelet reactivity unit (PRU) was assessed as a continuous outcome to estimate the impact on platelet physiology. A subgroup analysis of P2Y12i administered was performed. Nine studies comprising 1091 patients with ACS were included, 77% were males. Overall, 87% presented with ST-segment elevation acute myocardial infarction. Six studies administered Ticagrelor, while 3 studies used Prasugrel. The absolute risk of bleeding, assessed by TIMI, was low in both intervention and control arms (0.36% vs. 0.95% for major bleedings and 3.3% vs. 4.4% for minor bleedings), and crushed/chewed administration did not increase the relative risk of bleeding events for TIMI major or minor bleedings (RR 0.51, 95% CI 0.09-2.77, p = 0.293; RR 0.76, 95% CI 0.24-2.43, p = 0.542) or MACE (RR 0.94, 95% CI 0.28-3.19, p = 0.902). PRU was significantly reduced within 1 h after administration in the crushed/chewed P2Y12i group (MD: -70.0%, 95% CI, -89.0 to -51.1%, p<0.01) while we did not observe a significant difference after 4 h (MD: -15.1%, 95% CI -34.2 to 4.0%, p = 0.12). The type of drug did not influence the relative risk of crushed/chewed P2Y12i on major or minor bleeding (pinteraction = 0.62 and pinteraction = 0.23, respectively). The crushed/chewed administration of P2Y12i in the setting of ACS was not associated with an increased risk of bleeding, suggesting the safety of this strategy.

Patterns and Prognostic Impact of Postdischarge Ischemic, Bleeding, and Heart Failure Events After Myocardial Infarction

Although the in-hospital prognosis after acute myocardial infarction (AMI) has considerably improved to date, ischemic, bleeding, and heart failure (HF) events after discharge remain clinical challenges. However, the pattern of such events is not fully understood in contemporary clinical practice. This study aimed to evaluate the timing and prognostic impact of cardiovascular and bleeding events after AMI. This multicenter, retrospective registry included 2,059 patients with AMI who underwent percutaneous coronary intervention. Patients were grouped according to their first events after discharge, consisting of ischemic events (recurrent AMI or ischemic stroke), major bleeding, and HF hospitalization, whereas those without such events were classified as the no cardiovascular event group. All-cause mortality after discharge and the ischemic, bleeding, and HF events were evaluated. Ischemic events, major bleedings, and HF hospitalization as their first clinical outcome measures after discharge occurred in 99 (4.8%), 57 (2.8%), and 75 (3.6%) patients, respectively, during the median follow-up period of 538 days. Postdischarge mortality was highest in the major bleeding group, followed by the ischemic events, HF hospitalization, and no cardiovascular event groups. HF hospitalization occurred earlier than major bleeding and ischemic events after discharge. The mortality impact after the first events was greater in the major bleeding rather than ischemic events and HF hospitalization. In conclusion, patterns and prognostic impact of postdischarge outcomes differed significantly among ischemic, bleeding, and HF events, suggesting that timely and tailored follow-up may be needed after AMI.

High long-term mortality in ischaemic heart disease accentuated among ethnic minorities in Eastern Europe: findings from a prospective all-comers percutaneous coronary intervention registry in Romania

BACKGROUND

Long-term outcomes in cardiovascular diseases are historically under-reported in Eastern Europe. Our aim was to report long-term survival and to identify survival predictors in a prospective Romanian percutaneous coronary intervention (PCI) registry, with an emphasis on important under-resourced minorities, such as Hungarian and Roma ethnicities.

METHODS

An all-comers patient population treated by PCI in a tertiary cardiovascular centre that has been included prospectively in the local registry since January 2016 was analysed. Cardiovascular cause and all-cause mortality data were available as of December 2023.

RESULTS

A total of 6867 patients with 8442 PCI procedures were included. Romanian group consisted of 5095 (74.2%) patients, the Hungarian group consisted of 1417 (20.6%) patients and the Roma group consisted of 355 (5.1%) patients. During a median follow-up of 3.60 (1.35-5.75) years, a total of 1064 cardiovascular-cause and 1374 all-cause events occurred. Romanian, Hungarian and Roma patients suffered 5.12, 5.89 and 7.71 all-cause deaths per 100 patient-years, respectively. Romanian, Hungarian and Roma patients suffered 3.94, 4.63 and 6.22 cardiovascular-cause deaths per 100 patient-years, respectively. Both Hungarian and Roma patients presented significantly higher all-cause mortality than Romanian patients (adjusted HR (aHR)=1.20 (1.05-1.36), p=0.005 and aHR=1.51 (1.21-1.88), p=0.0001). Similarly, Hungarian and Roma patients presented significantly higher cardiovascular cause mortality than Romanian patients (aHR=1.22 (1.05-1.41), p=0.006 and aHR=1.51 (1.18-1.92), p=0.0008).

CONCLUSIONS

High long-term cardiovascular and all-cause mortality was observed for the entire included population. Long-term survival was significantly lower in ethnic minorities, such as the Hungarian and Roma minority than in the Romanian population.

The four-item PRECISE-DAPT score identifies coronary artery bypass grafting patients with increased risk for post-discharge major bleeding

AIMS

Early identification of patients with increased bleeding risk increases the possibility to individualize antithrombotic treatment. We validated the PRECISE-DAPT score, originally developed to estimate bleeding risk in patients on dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI), in coronary artery bypass grafting (CABG) patients.

METHODS AND RESULTS

All patients who underwent the first time, isolated CABG in Sweden 2009-2020 and survived until discharge were included. The four-item PRECISE-DAPT score, based on age, estimated glomerular filtration rate, pre-operative haemoglobin concentration, and previous spontaneous bleeding, was calculated in patients discharged on DAPT (n = 6838), or antiplatelet monotherapy (n = 15 406). High bleeding risk was defined as a score ≥25 in accordance with previous studies and major bleeding as hospitalization due to bleeding. Associations were assessed by C-statistics and Cox regression models. Major bleeding occurred during the first post-operative year in 130 patients (1.9%) in the DAPT group, and in 197 patients (1.3%) in the monotherapy group. The score identified 32.9% of the patients in the DAPT group and 38.2% in the monotherapy groups as having high bleeding risk. The area under the ROC-curve for the score was 0.67 (95%CI 0.62-0.72) for DAPT and 0.71 (0.67-0.74) for monotherapy. The hazard ratio for high bleeding risk vs. very low risk was 4.14 (2.07-8.26) for DAPT patients, and 4.95 (2.61-9.39) for monotherapy patients, both P < 0.001.

CONCLUSION

The PRECISE-DAPT identifies patients with increased risk for major bleeding after discharge following CABG with moderate accuracy. The accuracy is comparable to what previously has been reported for patients after PCI.

Low HDL Cholesterol is Associated with Reduced Bleeding Risk in Patients who Underwent PCI: Findings from the PRACTICE Study

BACKGROUND

 We sought to examine the dose-response relationship between high-density lipoprotein cholesterol (HDL-C) and bleeds in coronary artery disease (CAD) patients who underwent percutaneous coronary intervention (PCI).

METHODS

 All the 15,250 participants were from the Personalized Antiplatelet Therapy According to CYP2C19 Genotype in Coronary Artery Disease (PRACTICE) study, which is a large, single-center, prospective cohort study based on case records and a follow-up registry performed in the First Affiliated Hospital of Xinjiang Medical University from December 2016 to October 2021. We divided all the patients into five groups according to their HDL-C levels: the ≤35 mg/dL group (n = 4,732), 35 to 45 mg/dL group (n = 6,049), 45 to 55 mg/dL group (n = 2,826), 55 and 65 mg/dL group (n = 1,117), and >65 mg/dL group (n = 526). The incidence of bleeds, mortality, ischemic events, and net adverse clinical events (NACEs) among the five groups was compared.

RESULTS

 A total of 713 bleeds, 1,180 ischemic events, 456 deaths, and 1,893 NACEs were recorded during the up to 60-month follow-up period. After adjusting for confounders, we observed a nonlinear relation for bleeds, with the highest risk at intermediate HDL-C levels (45-55 mg/dL). We also identified a dose-response relationship for ischemic events. A threshold value of HDL-C ≤35 mg/dL (adjusted hazard ratio = 0.560, 95% confidence interval: 0.360-0.872, p = 0.010) was associated with a decreased risk for bleeds in the multivariable Cox regression model. The results were consistent in multiple sensitivity analyses and propensity score-matching analysis.

CONCLUSION

 In the present study, a nonlinear association was identified between HDL-C levels and bleeds in CAD patients who underwent PCI, with a higher risk at intermediate levels. However, further multicenter studies are warranted.

Hospital and Post-Discharge Mortality in Patients With Acute Coronary Syndrome and Ventricular Ectopy

INTRODUCTION

Ventricular premature depolarizations (VPDs) in the setting of acute coronary syndrome (ACS) were associated with increased hospital mortality in the early revascularization era.

OBJECTIVE

Examine the predictive value of VPDs and their morphology for hospital and post-discharge mortality in patients admitted for ACS.

METHODS

We identified patients admitted with ACS across 13 Northwell Health Hospitals from 2015 to 2021 and had VPDs captured on a 12-lead ECG or full disclose telemetry. We characterized and reported descriptively the VPDs based on bundle branch block pattern (right or RBBB vs. left or LBBB), frontal (inferior vs. superior) and horizontal (leftward vs. rightward) axis, QRS width, and coupling interval (CI). Hierarchical generalized linear mixed modeling was used to assess the association between VPDs and hospital mortality, while Cox regression was used for post-discharge mortality.

RESULTS

Of 18 009 patients admitted for ACS, we identified 627 patients with VPDs with complete data (65.7% RBB, 49.9% superior, and 63.4% leftward axis). Mean VPD QRS width and CI were 175 ± 30 and 523 ± 157 ms, respectively. Hospital mortality was higher in the VPD group (7.8% vs. 4.9%, p < 0.001) with most common mode of death being arrhythmic (28.1% vs. 14.5%). After adjusting for clinical covariates, only VPDs with RBBB patterns were associated with hospital mortality (OR 2.26, 95% CI 1.06-4.82). Conversely, age-adjusted post-discharge mortality was higher only for patients with superior axis VPDs (HR 1.59, 95% CI 1.13-2.24).

CONCLUSION

Among patients with VPDs during an ACS admission, presence of RBBB pattern predicts hospital mortality, whereas superior axis is associated with post-discharge mortality.

Relevance of High Bleeding Risk and Postdischarge Bleeding in Patients Undergoing Percutaneous Coronary Intervention

Bleeding avoidance strategies are critical in the modern era of percutaneous coronary intervention; however, most efforts are geared toward reducing access-related complications. Improvements in procedural techniques (radial access, improved procedural anticoagulation regimens, etc) and modifications in postdischarge pharmacotherapy (shortened dual antiplatelet therapy, genotype-guided P2Y12 inhibition, etc) that led to a decline in bleeding related to percutaneous procedures were largely offset by increases in complexity and performance of percutaneous coronary intervention in high-risk patients. Among patients presenting with acute coronary syndrome, aggressive antiplatelet regimens with potent P2Y12 inhibitors are typically prescribed for a longer duration, prioritizing reduction in ischemic events over bleeding risk. Because postdischarge bleeding connotes an adverse prognosis similar to an ischemic event, postprocedure freedom from adverse outcomes can be best tailored by individualizing and recognizing the patient's bleeding and ischemic risks. This review of the contemporary and historical literature (PubMed, EMBASE, Cochrane Library) summarizes the available data, provides strategies to navigate these complex decisions, and helps individualize antithrombotic therapy.

Oxidative Stress and Inflammation in Myocardial Ischemia-Reperfusion Injury: Protective Effects of Plant-Derived Natural Active Compounds

Acute myocardial infarction (AMI) remains a leading cause of death among patients with cardiovascular diseases. Percutaneous coronary intervention (PCI) has been the preferred clinical treatment for AMI due to its safety and efficiency. However, research indicates that the rapid restoration of myocardial oxygen supply following PCI can lead to secondary myocardial injury, termed myocardial ischemia-reperfusion injury (MIRI), posing a grave threat to patient survival. Despite ongoing efforts, the mechanisms underlying MIRI are not yet fully elucidated. Among them, oxidative stress and inflammation stand out as critical pathophysiological mechanisms, playing significant roles in MIRI. Natural compounds have shown strong clinical therapeutic potential due to their high efficacy, availability, and low side effects. Many current studies indicate that natural compounds can mitigate MIRI by reducing oxidative stress and inflammatory responses. Therefore, this paper reviews the mechanisms of oxidative stress and inflammation during MIRI and the role of natural compounds in intervening in these processes, aiming to provide a basis and reference for future research and development of drugs for treating MIRI.

Considerations in Antiplatelet Therapy in Women Undergoing Treatment of Acute Coronary Syndrome or Percutaneous Coronary Intervention

Antiplatelet therapy is integral to reduce the risk of future ischemic events following acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI); this aim must be balanced by limiting the risk of bleeding. Women with ACS or undergoing PCI have distinct platelet physiology, vascular anatomy, and clinical profiles that can influence the selection of an appropriate regimen. There are procedural techniques that can enhance safety in women. The poor inclusion of women in ACS and PCI trials limits our understanding of the ideal antiplatelet regimen in women, and future studies must find ways to increase the participation of female patients.

Gastrointestinal Bleeding After Percutaneous Coronary Intervention: Incidence, Risk Factors, and Outcomes

BACKGROUND

Percutaneous coronary intervention (PCI) is a well-established method for treating coronary artery disease. However, stent implantation necessitates the use of antiplatelet agents, which increases the risk of gastrointestinal bleeding (GIB). This study aims to assess the incidence, etiology, and outcomes of GIB within one year post-PCI at Sultan Qaboos University Hospital (SQUH), Muscat, Oman.

METHODS

This retrospective analysis included 435 patients who underwent PCI at SQUH between January and December 2017, excluding those with multiple PCI procedures and incomplete data. GIB was defined using the thrombolysis in myocardial infarction (timi) bleeding score. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, NY) with binary logistic regression employed to identify significant risk factors for GIB. A p-value < 0.05 was considered statistically significant.

RESULTS

GIB was identified in 15 patients (age 67.8 ± 8.8 years; 60% male), resulting in an incidence within one year post-PCI of 3.4%. Melena (53.3%) and hematemesis (20.0%) were the most frequent clinical presentations, with peptic ulcer disease being the predominant underlying etiology (40%). Significant risk factors included advanced age, chronic kidney disease, pre-existing peptic ulcer disease, and the use of non-steroidal anti-inflammatory drugs.

CONCLUSIONS

The incidence of GIB observed in this study aligns with previously reported rates. These findings highlight the importance of pre-PCI risk stratification for bleeding, especially in high-risk patients. Prophylactic measures, such as the use of gastric protective agents, should be considered to mitigate the risk of GIB in patients undergoing PCI.

Impact of proton pump inhibitor use on clinical outcomes in East Asian patients receiving clopidogrel following drug-eluting stent implantation

BACKGROUND

Concomitant use of clopidogrel and proton pump inhibitor (PPI) is common, but PPI may reduce the antiplatelet effects of clopidogrel in patients undergoing percutaneous coronary intervention (PCI). We evaluated the impact of PPI use on clinical outcomes in post-PCI patients, by incorporating P2Y12 reaction unit (PRU) and CYP2C19 genotyping results.

METHODS

From a multicenter registry of patients who underwent PCI with drug-eluting stent implantation and received clopidogrel-based dual antiplatelet therapy (DAPT), patients who were prescribed a PPI at the time of PCI (PPI users) were compared to those who were not (non-users). The primary outcome included all-cause death, myocardial infarction, stent thrombosis, or cerebrovascular accident at 12 months. Major bleeding (Bleeding Academic Research Consortium [BARC] types 3-5) and gastrointestinal (GI) bleeding (BARC types 3-5) were important secondary outcomes. The adjusted outcomes were compared using a 1:1 propensity-score (PS) matching and competing risk analysis.

RESULTS

Of 13,160 patients, 2,235 (17.0%) were prescribed PPI, with an average age of 65.4 years. PPI users had higher on-treatment PRU levels than non-users. After PS matching, the primary outcome occurred in 51 patients who were PPI users (cumulative incidence, 4.7%) and 41 patients who were non-users (cumulative incidence, 3.7%; log-rank p = 0.27). In carriers of both CYP2C19 loss-of-function alleles, PPI use was linked to an increased risk of the primary outcome (hazard ratio, 3.22; 95% confidence interval, 1.18-8.78). The incidence of major bleeding and GI bleeding (BARC types 3-5) was comparable between PPI users and non-users in the PS-matched cohort.

CONCLUSIONS

In post-PCI patients receiving clopidogrel-based DAPT, PPI use was not linked to an increased risk of adverse cardiac and cerebrovascular events, but there was a small but significant increase in on-treatment PRU. Future research using a more individualized approach would further elucidate these interactions and guide evidence-based clinical practices.

Aspirin: latest evidence and developments

Aspirin is a foundation drug of the pharmaceutical industry originally derived as an analgesic/anti-inflammatory agent but serendipitously discovered to have use as a prophylactic drug for major adverse cardiovascular events (MACE). Its modern-day utility in this latter role relies on its efficacy/safety balance in a contemporary population where, at least in high-income countries, age-standardised incident rates for MACE are falling, and where there are now competing therapeutic agents. Its future may be determined by its potential role as a chemoprophylactic or adjunct agent for cancer or other disease states. It therefore will continue to be the subject of further clinical research.

One-Month Dual Antiplatelet Therapy in High Bleeding Risk Asian Patients Undergoing Percutaneous Coronary Intervention - Onyx ONE Clear 2-Year Results

Background

One-month dual antiplatelet therapy (DAPT) in high bleeding risk (HBR) patients undergoing percutaneous coronary intervention (PCI) with the Resolute OnyxTM zotarolimus-eluting stents (ZES) is safe and effective. Asian patients have a unique ischemia/bleeding risk profile. Here, we compare the outcomes between Asian and non-Asian patients after PCI and 1-month DAPT.

Methods and Results

Onyx ONE Clear was a prospective, multicenter study enrolling HBR patients undergoing PCI with the Resolute Onyx ZES (ClinicalTrials.gov identifier NCT03647475). Event-free patients after 1-month DAPT transitioned to single antiplatelet therapy. Clinical outcomes between 1 month and 2 years were compared between patients from Asian and non-Asian countries after 1 : 1 propensity score matching accounting for baseline differences. Patients from Asian countries represented 18% (n=273) of the study group (n=1,507). Non-Asian patients had greater clinical complexity; however, these differences were minimal after matching. There were no significant differences in ischemic outcomes between matched cohorts from 1 month to 2 years, including the primary composite endpoint of cardiac death or myocardial infarction (12% vs. 12%; P>0.99). However, there were significantly fewer Bleeding Academic Research Consortium types 3-5 bleeding events in the Asian vs. non-Asian cohort (4% vs. 9%; P=0.007), despite similar bleeding risk profiles after matching.

Conclusions

After propensity score matching, HBR patients from Asian countries undergoing PCI treated with 1-month DAPT had similar ischemic outcomes but fewer bleeding events between 1 month and 2 years compared with patients from non-Asian countries.

Transfusion and clinical outcomes after percutaneous coronary intervention

We investigated the long-term patterns and effects of transfusion on the clinical outcome of patients undergoing percutaneous coronary intervention (PCI) using a nationwide registry. Five-year clinical outcome of all Koreans undergoing PCI using stent in year 2011 (n = 48,786) was investigated. Primary outcome was the incidence density of transfusion. The association of transfusion with major adverse clinical event (MACE) consisting all-cause death, revascularization, critically ill cardiovascular status, or stroke was assessed after adjusting the propensity of each patient for transfusion. The 5-year incidence density of transfusion was 4.74 (95% confidence interval [CI] 4.70-4.79) per 100 person-year. Patients who received transfusion were older and had higher frequency of clinical risk factors (p < 0.001, all). Transfusion was associated with MACE (hazard ratio [HR] 3.2, 95% CI 3.2-3.3, p < 0.001) and all other clinical events (HR 1.5-6.9, p < 0.001, all). The period of transfusion coincided with the period of highest MACE incidence density. Subgroup analyses showed consistent results. Within 5 years after PCI, a total of 22.9% of patients received transfusion and had a 3.2-fold higher risk of MACE compared to patients without transfusion.

Review of the Ticagrelor Trials Evidence Base

Ticagrelor is a platelet P2Y12 receptor inhibitor approved for use in patients with acute coronary syndromes, coronary artery disease, and low-moderate risk acute ischemic stroke or high-risk transient ischemic attack. Clinical trials have evaluated the efficacy and safety of ticagrelor on ischemic and bleeding outcomes for different indications and with varying treatment approaches. As a result, there is a large body of clinical evidence demonstrating different degrees of net clinical benefit compared with other platelet inhibitor drugs based on indication, patient characteristics, clinical presentation, treatment duration, and other factors. We provide a review of the major trials of ticagrelor in the context of other randomized trials of clopidogrel and prasugrel to organize the volume of available information, elevate corroborating and conflicting data, and identify potential gaps as areas for further exploration of optimal antiplatelet treatment.

Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease With Recent or Remote Events: Systematic Review and Meta-analysis

Background

Ongoing debate remains regarding optimal antithrombotic therapy in patients with atrial fibrillation (AF) and coronary artery disease.

Methods

We performed a systematic review and meta-analysis to synthesize randomized controlled trials (RCTs) comparing the following: (i) dual-pathway therapy (DPT; oral anticoagulant [OAC] plus antiplatelet) vs triple therapy (OAC and dual-antiplatelet therapy) after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS), and (iii) OAC monotherapy vs DPT at least 1 year after PCI or ACS. Following a 2-stage process, we identified systematic reviews published between 2019 and 2022 on these 2 clinical questions, and we updated the most comprehensive search for additional RCTs published up to October 2022. Outcomes of interest were major adverse cardiovascular events (MACE), death, stent thrombosis, and major bleeding. We estimated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model.

Results

Based on 6 RCTs (n = 10,435), DPT reduced major bleeding (RR 0.62, 95% CI 0.52-0.73) and increased stent thrombosis (RR 1.55, 95% CI 1.02-2.36), vs triple therapy after PCI or medically-managed ACS, with no significant differences in MACE and death. In 2 RCTs (n = 2905), OAC monotherapy reduced major bleeding (RR 0.66, 95% CI 0.49-0.91) vs DPT in AF patients with remote PCI or ACS, with no significant differences in MACE or death.

Conclusions

In patients with AF and coronary artery disease, using less-aggressive antithrombotic treatment (DPT after PCI or ACS, and OAC alone after remote PCI or ACS) reduced major bleeding, with an increase in stent thrombosis with recent PCI. These results support a minimalist yet personalized antithrombotic strategy for these patients.

Aetiology and predictors of major bleeding events in patients with heart failure with reduced ejection fraction undergoing percutaneous coronary intervention

OBJECTIVES

We sought to determine the relationship between the degree of left ventricular ejection fraction (LVEF) impairment and the frequency and type of bleeding events after percutaneous coronary intervention (PCI).

DESIGN

This was an observational retrospective cohort analysis. Patients who underwent PCI from 2009 to 2017 were identified from our institutional National Cardiovascular Disease Registry (NCDR) CathPCI database. Patients were stratified by pre-PCI LVEF: preserved (≥50%), mildly reduced (41%-49%) and reduced (≤40%) LVEF.

PRIMARY OUTCOME MEASURES

The outcome was major bleeding, defined by NCDR criteria. Events were classified based on bleeding aetiology and analysed by multivariable logistic regression.

RESULTS

Among 13 537 PCIs, there were 817 bleeding events (6%). The rate of bleeding due to any cause, blood transfusion, gastrointestinal bleeding and coronary artery perforation or tamponade each increased in a stepwise fashion comparing preserved, mildly reduced and reduced LVEF reduction (p<0.05 for all comparisons). However, there were no differences in bleeding due to asymptomatic drops in haemoglobin, access site haematoma or retroperitoneal bleeding. After multivariable adjustment, mildly reduced and reduced LVEF remained independent predictors of bleeding events (OR 1.36, 95% CI 1.06 to 1.74, p<0.05 and OR 1.73, 95% CI 1.45 to 2.06, p<0.0001).

CONCLUSIONS

The degree of LV dysfunction is an independent predictor of post-PCI major bleeding events. Patients with mildly reduced or reduced LVEF are at greatest risk of post-PCI bleeding, driven by an increased need for blood transfusion, major GI bleeding events and coronary artery perforation or tamponade. Pre-PCI LV dysfunction does not predict asymptomatic declines in haemoglobin, access site haematoma or retroperitoneal bleeding.

Effectiveness of Clopidogrel vs Alternative P2Y12 Inhibitors Based on the ABCD-GENE Score

BACKGROUND

An ABCD-GENE (age, body mass index, chronic kidney disease, diabetes, and CYP2C19 genetic variants) score ≥10 predicts reduced clopidogrel effectiveness, but its association with response to alternative therapy remains unclear.

OBJECTIVES

The aim of this study was to evaluate the association between ABCD-GENE score and the effectiveness of clopidogrel vs alternative P2Y12 inhibitor (prasugrel or ticagrelor) therapy after percutaneous coronary intervention (PCI).

METHODS

A total of 4,335 patients who underwent PCI, CYP2C19 genotyping, and P2Y12 inhibitor treatment were included. The primary outcome was major atherothrombotic events (MAE) within 1 year after PCI. Cox regression was performed to assess event risk in clopidogrel-treated (reference) vs alternatively treated patients, with stabilized inverse probability weights derived from exposure propensity scores after stratifying by ABCD-GENE score and further by CYP2C19 loss-of-function (LOF) genotype.

RESULTS

Among patients with scores <10 (n = 3,200), MAE was not different with alternative therapy vs clopidogrel (weighted HR: 0.89; 95% CI: 0.65-1.22; P = 0.475). The risk for MAE also did not significantly differ by treatment among patients with scores ≥10 (n = 1,135; weighted HR: 0.75; 95% CI: 0.51-1.11; P = 0.155). Among CYP2C19 LOF allele carriers, MAE risk appeared lower with alternative therapy in both the group with scores <10 (weighted HR: 0.50; 95% CI: 0.25-1.01; P = 0.052) and the group with scores ≥10 (weighted HR: 0.48; 95% CI: 0.29-0.80; P = 0.004), while there was no difference in the group with scores <10 and no LOF alleles (weighted HR: 1.03; 95% CI: 0.70-1.51; P = 0.885).

CONCLUSIONS

These data support the use of alternative therapy over clopidogrel in CYP2C19 LOF allele carriers after PCI, regardless of ABCD-GENE score, while clopidogrel is as effective as alternative therapy in non-LOF patients with scores <10.

Postdischarge major bleeding, myocardial infarction, and mortality risk after coronary artery bypass grafting

OBJECTIVE

To investigate the incidence and mortality risk associated with postdischarge major bleeding after coronary artery bypass grafting (CABG), and relate this to the incidence of, and mortality risk from, postdischarge myocardial infarction.

METHODS

All patients undergoing first-time isolated CABG in Sweden in 2006-2017 and surviving 14 days after hospital discharge were included in a cohort study. Individual patient data from the SWEDEHEART Registry and five other mandatory nationwide registries were merged. Piecewise Cox proportional hazards models were used to investigate associations between major bleeding, defined as hospitalisation for bleeding, with subsequent mortality risk. Similar Cox proportional hazards models were used to investigate the association between postdischarge myocardial infarction and mortality risk.

RESULTS

Among 36 633 patients, 2429 (6.6%) had a major bleeding event and 2231 (6.1%) had a myocardial infarction. Median follow-up was 6.0 (range 0-11) years. Major bleeding was associated with higher mortality risk <30 days (adjusted HR (aHR)=20.2 (95% CI 17.3 to 23.5)), 30-365 days (aHR=3.8 (95% CI 3.4 to 4.3)) and >365 days (aHR=1.8 (95% CI 1.7 to 2.0)) after the event. Myocardial infarction was associated with higher mortality risk <30 days (aHR=20.0 (95% CI 16.7 to 23.8)), 30-365 days (aHR=4.1 (95% CI 3.6 to 4.8)) and >365 days (aHR=1.8 (95% CI 1.7 to 2.0)) after the event.

CONCLUSIONS

The increase in mortality risk associated with a postdischarge major bleeding after CABG is substantial and is similar to the mortality risk associated with a postdischarge myocardial infarction.

Age and Aspirin Dosing in Secondary Prevention of Atherosclerotic Cardiovascular Disease

BACKGROUND

In patients with atherosclerotic cardiovascular disease, increasing age is concurrently associated with higher risks of ischemic and bleeding events. The objectives are to determine the impact of aspirin dose on clinical outcomes according to age in atherosclerotic cardiovascular disease.

METHODS AND RESULTS

In the ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) trial, patients with atherosclerotic cardiovascular disease were randomized to daily aspirin doses of 81 mg or 325 mg. The primary effectiveness end point was death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke. The primary safety end point was hospitalization for bleeding requiring transfusion. A total of 15 076 participants were randomized to aspirin 81 mg (n=7540) or 325 mg (n=7536) daily (median follow-up: 26.2 months; interquartile range: 19.0-34.9 months). Median age was 67.6 years (interquartile range: 60.7-73.6 years). Among participants aged <65 years (n=5841 [38.7%]), a primary end point occurred in 226 (7.54%) in the 81 mg group, and in 191 (6.80%) in the 325 mg group (adjusted hazard ratio [HR], 1.23 [95% CI, 1.01-1.49]). Among participants aged ≥65 years (n=9235 [61.3%]), a primary end point occurred in 364 (7.12%) in the 81 mg group, and in 378 (7.96%) in the 325 mg group (adjusted HR, 0.95 [95% CI, 0.82-1.10]). The age-dose interaction was not significant (P=0.559). There was no significant interaction between age and the randomized aspirin dose for the secondary effectiveness and the primary safety bleeding end points (P>0.05 for all).

CONCLUSIONS

Age does not modify the impact of aspirin dosing (81 mg or 325 mg daily) on clinical end points in secondary prevention of atherosclerotic cardiovascular disease.

Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy

Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.

The prevalence of bleeding after percutaneous coronary interventions: A systematic review and meta-analysis

BACKGROUND

Bleeding is a common complication associated with percutaneous coronary intervention (PCI). The aim of this study was to determine the prevalence of bleeding after PCI through a systematic review and meta-analysis.

METHODS

The systematic review and meta-analysis covered the period from 1989 to 2023. Multiple databases, including Embase, PubMed, Scopus, Web of Sciences (WoS), MagIran, Scientific Information Database (SID), and Google Scholar, were searched using validated keywords with MeSH and Emtree. The I2 index was used to check for heterogeneity among studies.

RESULTS

The review of 8 studies, with a sample size of 397,298 participants, showed high heterogeneity (I2: 97.8 %). Therefore, the random effects method was used to analyze the results. The prevalence of bleeding after intervention in percutaneous coronary arteries was reported to be 4.4 % (95%CI: 2-9.1).

CONCLUSION

This meta-analysis showed a significant prevalence of bleeding after PCI, highlighting the need for health policymakers to pay more attention to the complications associated with PCI. Interventional cardiologists should consider the effective factors in these bleeding and how to treat and control them due to the importance of this complication.

De-escalation from ticagrelor to clopidogrel in patients with acute myocardial infarction: the TALOS-AMI HBR substudy

BACKGROUND

The benefits of de-escalation of P2Y12 inhibition after percutaneous coronary intervention (PCI) may differ by high bleeding risk (HBR) status.

AIMS

We investigated the efficacy and safety of de-escalation from ticagrelor to clopidogrel after PCI by HBR status.

METHODS

This is a non-prespecified post hoc analysis of the TicAgrelor Versus CLOpidogrel in Stabilized Patients with Acute Myocardial Infarction (TALOS-AMI) trial. Net adverse clinical events (a composite of cardiovascular death, myocardial infarction, stroke, or Bleeding Academic Research Consortium [BARC] bleeding type 2, 3, or 5) at 1 year post-PCI were compared between the de-escalation (clopidogrel plus aspirin) and the active control (ticagrelor plus aspirin) groups by HBR status, as defined by the modification of the Academic Research Consortium (ARC) criteria.

RESULTS

A total of 2,625 patients in the TALOS-AMI trial were analysed. Of these, 589 (22.4%) met the modified ARC-HBR criteria. The de-escalation group had lower primary endpoint rates than the control group in both HBR (hazard ratio [HR] 0.47, 95% confidence interval [CI]: 0.26-0.84) and non-HBR (HR 0.59, 95% CI: 0.41-0.84) patients. There were no differences in treatment effect for the primary endpoint regardless of HBR status (p for interaction=0.904). BARC bleeding type 3 or 5 was less common in the de-escalation than the control group among HBR patients only (HR 0.24, 95% CI: 0.07-0.84).

CONCLUSIONS

In stabilised acute myocardial infarction patients, unguided de-escalation from ticagrelor to clopidogrel was associated with a lower rate of net adverse clinical outcomes irrespective of HBR status. The effect of de-escalation of P2Y12 inhibition on reducing haemorrhagic events was greater in patients with HBR.

Paired risk scores to predict ischaemic and bleeding risk twenty-eight days to one year after an acute coronary syndrome

OBJECTIVE

The recommended duration of dual anti-platelet therapy (DAPT) following acute coronary syndrome (ACS) varies from 1 month to 1 year depending on the balance of risks of ischaemia and major bleeding. We designed paired ischaemic and major bleeding risk scores to inform this decision.

METHODS

New Zealand (NZ) patients with ACS investigated with coronary angiography are recorded in the All NZ ACS Quality Improvement registry and linked to national health datasets. Patients were aged 18-84 years (2012-2020), event free at 28 days postdischarge and without atrial fibrillation. Two 28-day to 1-year postdischarge multivariable risk prediction scores were developed: (1) cardiovascular mortality/rehospitalisation with myocardial infarction or ischaemic stroke (ischaemic score) and (2) bleeding mortality/rehospitalisation with bleeding (bleeding score).

FINDINGS

In 27 755 patients, there were 1200 (4.3%) ischaemic and 548 (2.0%) major bleeding events. Both scores were well calibrated with moderate discrimination performance (Harrell's c-statistic 0.75 (95% CI, 0.74 to 0.77) and 0.69 (95% CI, 0.67 to 0 .71), respectively). Applying these scores to the 2020 European Society of Cardiology ACS antithrombotic treatment algorithm, the 31% of the cohort at elevated (>2%) bleeding and ischaemic risk would be considered for an abbreviated DAPT duration. For those at low bleeding risk, but elevated ischaemic risk (37% of the cohort), prolonged DAPT may be appropriate, and for those with low bleeding and ischaemic risk (29% of the cohort) short duration DAPT may be justified.

CONCLUSION

We present a pair of ischaemic and bleeding risk scores specifically to assist clinicians and their patients in deciding on DAPT duration beyond the first month post-ACS.

Long-term outcomes of periprocedural coronary dissection and perforation for patients undergoing percutaneous coronary intervention in a Japanese multicenter registry

Long-term outcomes of iatrogenic coronary dissection and perforation in patients undergoing percutaneous coronary intervention (PCI) remains under-investigated. We analyzed 8,721 consecutive patients discharged after PCI between 2008 and 2019 from Keio Cardiovascular (KiCS) PCI multicenter prospective registry in the Tokyo metropolitan area. Significant coronary dissection was defined as persistent contrast medium extravasation or spiral or persistent filling defects with complete distal and impaired flow. The primary outcome was a composite of all-cause death, acute coronary syndrome, heart failure, bleeding, stroke requiring admission, and coronary artery bypass grafting two years after discharge. We used a multivariable Cox hazard regression model to assess the effects of these complications. Among the patients, 68 (0.78%) had significant coronary dissections, and 61 (0.70%) had coronary perforations at the index PCI. Patients with significant coronary dissection had higher rates of the primary endpoint and heart failure than those without (25.0% versus 14.3%, P = 0.02; 10.3% versus 4.2%, P = 0.03); there were no significant differences in the primary outcomes between the patients with and without coronary perforation (i.e., primary outcome: 8.2% versus 14.5%, P = 0.23) at the two-year follow-up. After adjustments, patients with coronary dissection had a significantly higher rate of the primary endpoint than those without (HR 1.70, 95% CI 1.02-2.84; P = 0.04), but there was no significant difference in the primary endpoint between the patients with and without coronary perforation (HR 0.51, 95% CI 0.21-1.23; P = 0.13). For patients undergoing PCI, significant coronary dissection was associated with poor long-term outcomes, including heart failure readmission.

High Platelet Reactivity Combined with CYP2C19 Genotype in Predicting Outcomes in East Asian Patients Undergoing Percutaneous Coronary Intervention

Loss-of-function (LoF) alleles of cytochrome P450 2C19 (CYP2C19), which are prevalent in East Asians, are linked to high platelet reactivity (HPR) phenotype and poor prognosis. We aimed to investigate the incremental predictive value of HPR combined with CYP2C19 genotype in predicting outcomes after drug-eluting stent (DES) implantation. The patients treated with platelet function and genotype-related long-term prognosis in drug-eluting stent (PTRG-DES) consortium enrolled a total of 13,160 Korean patients treated with DES who had platelet function test (PFT) or CYP2C19 genotype, of which, 6,717 patients with PFT and genotype together were categorized. HPR was defined as VerifyNow ≥ 252 P2Y12 reaction unit. The primary outcome was the incidence of major adverse cardiac and cerebrovascular event (MACCE) 5 years after treatment. The patients with both HPR and CYP2C19 LoF/LoF had the highest MACCE rates (6.2%) and increased MACCE risk (adjusted hazard ratio: 1.89, 95% confidence interval: 1.20-2.91, P = 0.006) compared with those without both HPR and CYP2C19 LoF/LoF. There was no effect of interaction between HPR and CYP2C19 genotype on the primary outcome (P = 0.424). Adding combined HPR and CYP2C19 genotype to the conventional model had an incremental influence in predicting MACCE and stent thrombosis. Compared to the model including HPR or CYP2C19 genotype alone, a combination model significantly improved the risk stratification for stent thrombosis but not MACCE. In DES-treated East Asian patients, the combined evaluation of PFT results and CYP2C19 genotyping might improve risk prediction of ischemic events during clopidogrel treatment.

Current concepts and novel targets for antiplatelet therapy

Platelets have a crucial role in haemostasis and atherothrombosis. Pharmacological control of platelet hyper-reactivity has become a cornerstone in the prevention of thrombo-ischaemic complications in atherosclerotic diseases. Current antiplatelet therapies substantially improve clinical outcomes in patients with coronary artery disease, but at the cost of increased risk of bleeding. Beyond their role in thrombosis, platelets are known to regulate inflammatory (thrombo-inflammatory) and microcirculatory pathways. Therefore, controlling platelet hyper-reactivity might have implications for both tissue inflammation (myocardial ischaemia) and vascular inflammation (vulnerable plaque formation) to prevent atherosclerosis. In this Review, we summarize the pathophysiological role of platelets in acute myocardial ischaemia, vascular inflammation and atherosclerotic progression. Furthermore, we highlight current clinical concepts of antiplatelet therapy that have contributed to improving patient care and have facilitated more individualized therapy. Finally, we discuss novel therapeutic targets and compounds for antiplatelet therapy that are currently in preclinical development, some of which have a more favourable safety profile than currently approved drugs with regard to bleeding risk. These novel antiplatelet targets might offer new strategies to treat cardiovascular disease.

Short dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk patients: Systematic review and meta-analysis

INTRODUCTION

Dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) reduces major adverse cardiovascular events (MACE) and stent thrombosis. However, DAPT duration is a concern in high bleeding risk (HBR) patients. We evaluated the effect of short DAPT (1-3 months) compared to standard DAPT (6-12 months) on bleeding and ischemic events in HBR PCI.

METHODS

We searched MEDLINE, Embase and CENTRAL up to August 18, 2022. Randomized controlled trials (RCTs) comparing short DAPT (1-3 months) versus standard DAPT in HBR PCI were included. We assessed risk of bias (RoB) using the Cochrane RoB2 tool, and certainty of evidence using GRADE criteria. Outcomes included MACE, all-cause death, stent thrombosis, major bleeding, and the composite of major or clinically-relevant non-major bleeding. We estimated risk ratios (RR) and 95% confidence intervals (CI) using a random-effects model.

RESULTS

From 503 articles, we included five RCTs (n = 7,242) at overall low risk of bias with median follow-up of 12-months. Compared to standard DAPT, short DAPT did not increase MACE (RR 1.02, 95% CI 0.84-1.23), all-cause death (RR 0.92, 95% CI 0.71-1.20) or stent thrombosis (RR 1.47, 95% CI 0.73-2.93). Short DAPT reduced major bleeding (RR 0.34, 95% CI 0.13-0.90) and the composite of major or clinically-relevant non-major bleeding (RR 0.60, 95% CI 0.44-0.81), translating to 21 and 34 fewer events, respectively, per 1000 patients.

CONCLUSIONS

In HBR PCI, DAPT for 1-3 months compared to 6-12 months reduced clinically-relevant bleeding events without jeopardizing ischemic risk. Short DAPT should be considered in HBR patients receiving PCI.

Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management

INTRODUCTION

In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks.

AREAS COVERED

This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications.

EXPERT OPINION

Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.

Assessment of Nonfatal Bleeding Events as a Surrogate for Mortality in Coronary Artery Disease

Background

Bleeding events are frequently applied as safety end points for randomized controlled trials (RCTs) investigating the effect of antithrombotic agents in patients with coronary artery disease. However, whether a bleeding event is a valid surrogate for death remain uncertain.

Objectives

This study aimed to assess the correlation between the treatment effect on bleeding events and mortality.

Methods

Multiple databases were searched to identify RCTs studying antithrombotic agents for patients with coronary artery disease through August 2022. Major and minor bleeding events were defined in included trials, mostly defined with BARC (Bleeding Academic Research Consortium) or TIMI (Thrombolysis In Myocardial Infarction) criteria. Trial-level correlations between nonfatal bleeding events and mortality were assessed. We performed subgroup analyses by the definitions of bleeding (BARC vs TIMI criteria), study year, and follow-up duration. We used a cutoff with a lower limit of 95% confidence interval of R2 >0.72 as a strong correlation and with an upper limit of 95% confidence interval of R2 <0.50 as a weak correlation.

Results

A total of 48 RCTs with 181,951 participants were analyzed. Overall, trial-level R2 for major and minor bleeding were 0.09 (95% CI: 0.00-0.26) and 0.09 (95% CI: 0.00-0.27) for all-cause or cardiovascular death, respectively. When confined to major bleeding, R2 were 0.03 (95% CI: 0.00-0.13) and 0.01 (95% CI: 0.00-0.05), respectively. All of the subgroup analyses did not show any significant correlations.

Conclusions

We demonstrated a trial-defined bleeding event may not be a valid surrogate for mortality in RCTs investigating the effect of antithrombotic agents for coronary artery disease.

Unsupervised Machine Learning with Cluster Analysis in Patients Discharged after an Acute Coronary Syndrome: Insights from a 23,270-Patient Study

Characterization and management of patients admitted for acute coronary syndromes (ACS) remain challenging, and it is unclear whether currently available clinical and procedural features can suffice to inform adequate decision making. We aimed to explore the presence of specific subsets among patients with ACS. The details on patients discharged after ACS were obtained by querying an extensive multicenter registry and detailing patient features, as well as management details. The clinical outcomes included fatal and nonfatal cardiovascular events at 1-year follow-up. After missing data imputation, 2 unsupervised machine learning approaches (k-means and Clustering Large Applications [CLARA]) were used to generate separate clusters with different features. Bivariate- and multivariable-adjusted analyses were performed to compare the different clusters for clinical outcomes. A total of 23,270 patients were included, with 12,930 cases (56%) of ST-elevation myocardial infarction (STEMI). K-means clustering identified 2 main clusters: a first 1 including 21,998 patients (95%) and a second 1 including 1,282 subjects (5%), with equal distribution for STEMI. CLARA generated 2 main clusters: a first 1 including 11,268 patients (48%) and a second 1 with 12,002 subjects (52%). Notably, the STEMI distribution was significantly different in the CLARA-generated clusters. The clinical outcomes were significantly different across clusters, irrespective of the originating algorithm, including death reinfarction and major bleeding, as well as their composite. In conclusion, unsupervised machine learning can be leveraged to explore the patterns in ACS, potentially highlighting specific patient subsets to improve risk stratification and management.

Treatment strategies of acute myocardial infarction: updates on revascularization, pharmacological therapy, and beyond

Owing to recent advances in early reperfusion strategies, pharmacological therapy, standardized care, and the identification of vulnerable patient subsets, the prognosis of acute myocardial infarction has improved. However, there is still considerable room for improvement. This review article summarizes the latest evidence concerning clinical diagnosis and treatment of acute myocardial infarction.

Long-Term Outcomes of Randomized Controlled Trials Comparing Percutaneous Left Atrial Appendage Closure to Oral Anticoagulation for Nonvalvular Atrial Fibrillation: A Meta-Analysis

Background

Oral anticoagulation (OAC) has been considered the standard of care for stroke prophylaxis for patients with nonvalvular atrial fibrillation; however, many individuals are unable or unwilling to take long-term OAC. The safety and efficacy of percutaneous left atrial appendage closure (LAAC) have been controversial, and new trial data have recently emerged. We therefore sought to perform an updated meta-analysis of randomized clinical trials (RCTs) comparing OAC to percutaneous LAAC, focusing on individual clinical endpoints.

Methods

We performed a systematic search of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from January 2000 through December 2021 for all RCTs comparing percutaneous LAAC to OAC in patients with nonvalvular atrial fibrillation. Fixed and random effects meta-analyses of hazard ratios (HRs) were performed using the longest follow-up duration available by intention-to-treat. The prespecified primary endpoint was all-cause mortality.

Results

Three RCTs enrolling 1516 patients were identified. The weighted mean follow-up was 54.7 months. LAAC was associated with a reduced risk of all-cause mortality (HR 0.76; 95% confidence interval [CI], 0.59-0.96; p = 0.023), hemorrhagic stroke (HR 0.24; 95% CI, 0.09-0.61; p = 0.003), and major nonprocedural bleeding (HR 0.52; 95% CI, 0.37-0.74; p < 0.001). There was no significant difference between LAAC and OAC for any other endpoints.

Conclusions

The available evidence from RCTs suggests LAAC therapy is associated with reduced long-term risk of death compared with OAC. This may be driven by reductions in hemorrhagic stroke and major nonprocedural bleeding. There were no significant differences in the risk of all stroke. Further large-scale clinical trials are needed to validate these findings.

The Evolution of Antiplatelet Therapy After Percutaneous Coronary Interventions: A 40-Year Journey

Antiplatelet therapy has a critical role to play in the successful management of patients undergoing percutaneous coronary intervention (PCI). Over the past 40 years, a multitude of participants worldwide have been enrolled in trials evaluating the impact of antiplatelet agents on clinical outcomes. The use of aspirin in unstable angina in the Canadian Aspirin trial was key to establishing the benefit of aspirin in acute coronary syndrome. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial demonstrated that the P2Y12 inhibitor clopidogrel, when added to aspirin, reduced major cardiovascular events. While the use of antiplatelet agents in coronary artery disease antedates the introduction of PCI and remains the cornerstone of secondary prevention of atherosclerotic cardiovascular disease, strategies aiming to optimise their best use are still constantly evolving. In this review, the major randomised trials shaping current clinical practice for the use of aspirin and P2Y12 inhibitors in patients undergoing PCI are summarised, with a focus on aspirin-free strategies and on the role of P2Y12 inhibitor treatment before PCI, two major topics of ongoing investigation that are critical to patient care but that are not addressed in current practice guidelines. Multiple questions remain regarding the use of antiplatelet agents after PCI, including the personalisation of dosing, intensity, pharmacologic formulation, and duration of antiplatelet therapy based on individual patient characteristics and the optimal treatment of patients at high bleeding risk.

Serum VCAM-1 and ICAM-1 measurement assists for MACE risk estimation in ST-segment elevation myocardial infarction patients

Background

Vascular cell adhesion molecule‐1 (VCAM‐1) and intercellular adhesion molecule‐1 (ICAM‐1) modulate atherosclerosis by promoting leukocyte infiltration, neutrophil recruitment, endothelial cell proliferation, etc., which may directly or indirectly facilitate the occurrence of major adverse cardiac events (MACE). This study intended to investigate the value of VCAM‐1 and ICAM‐1 for predicting MACE in ST‐segment elevation myocardial infarction (STEMI) patients.

Methods

Totally, 373 STEMI patients receiving the percutaneous coronary intervention and 50 health controls (HCs) were included. Serum VCAM‐1 and ICAM‐1 were detected by ELISA. Meanwhile, MACE was recorded during a median follow‐up of 18 (range: 1–46) months in STEMI patients.

Results

Vascular cell adhesion molecule‐1 and ICAM‐1 were raised in STEMI patients compared with HCs (both p < 0.001). VCAM‐1 (p = 0.002) and ICAM‐1 (p = 0.012) high were linked with raised accumulating MACE rate in STEMI patients. Notably, VCAM‐1 high (hazard ratio [HR] = 2.339, p = 0.031), age ≥ 65 years (HR = 2.019, p = 0.039), history of diabetes mellitus (DM) (HR = 2.395, p = 0.011), C‐reactive protein (CRP) ≥ 5 mg/L (HR = 2.550, p = 0.012), multivessel disease (HR = 2.561, p = 0.007) independently predicted MACE risk in STEMI patients. Furthermore, a nomogram‐based prediction model combining these factors was established, exhibiting an acceptable value for estimating 1, 2, and 3‐year MACE risk, with AUC of 0.764, 0.716, and 0.778, respectively, in STEMI patients.

Conclusion

This study confirms the value of VCAM‐1 and ICAM‐1 measurement in predicting MACE risk in STEMI patients. Moreover, VCAM‐1 plus other traditional prognostic factors (such as age, history of DM, CRP, and multivessel disease) cloud further improve the predictive accuracy of MACE risk in STEMI patients.

Incidence, Prediction, and Outcomes of Major Bleeding After Percutaneous Coronary Intervention in Chinese Patients

BACKGROUND

The patterns of late major bleeding (MB) after percutaneous coronary intervention (PCI) remain unknown in Chinese patients.

OBJECTIVES

This study sought to determine the incidence, prediction, and long-term outcomes of late MB in Chinese patients.

METHODS

This was a retrospective cohort study from 14 hospitals in Hong Kong. Participants were patients undergoing first-time PCI without MB within 30 days or death within 1 year. Patients were stratified by the presence of late MB, defined as MB between 30 and 365 days. The primary endpoint was all-cause mortality. The secondary endpoints were major adverse cardiac events (MACE).

RESULTS

A total of 32,057 patients were analyzed. After adjustment for baseline characteristics, periprocedural characteristics, and medications on discharge, the risks of all-cause mortality at 5 years were significantly higher with late MB (HR: 2.15; 95% CI: 1.92-2.41; P < 0.001). Late MB was also associated with a higher risk of MACE (HR: 1.57; 95% CI: 1.03-1.50; P < 0.001), myocardial infarction (HR: 1.25; 95% CI: 1.04-1.52; P = 0.02), and stroke (HR: 1.38; 95% CI: 1.09-1.73; P = 0.006). The CARDIAC (anti-Coagulation therapy, Age, Renal insufficiency, Drop In hemoglobin, baseline Anemia in Chinese patients) score had a good discriminating power for prediction of MB within 365 days (area under the receiver-operating characteristic curve: 0.76).

CONCLUSIONS

Late MB was independently associated with a higher risk of mortality, MACE, myocardial infarction, and stroke in patients undergoing PCI. The CARDIAC score is a simple model that can predict MB after PCI. Prevention of MB represents an important strategy to optimize cardiovascular outcomes for patients undergoing PCI.

Antiplatelet Therapy in Atherothrombotic Diseases: Similarities and Differences Across Guidelines

Antiplatelet therapy, mainly consisting of aspirin and P2Y₁₂ receptor antagonists, is the cornerstone of the pharmacological treatment and prevention of atherothrombotic diseases. Its use, especially in secondary cardiovascular prevention, has significantly improved patient clinical outcomes in the last decades. Primary safety endpoint (i.e., bleeding complications) remain a major drawback of antiplatelet drugs. National and international societies have published and regularly updated guidelines for antiplatelet therapy aiming to provide clinicians with practical recommendations for a better handling of these drugs in various clinical settings. Many recommendations find common ground between international guidelines, but certain strategies vary across the countries, particularly with regard to the choice of molecules, dosage, and treatment duration. In this review, we detail and discuss the main antiplatelet therapy indications in the light of the different published guidelines and the significant number of recently published clinical trials and meta-analyses and highlight the areas that deserve further investigation in order to improve antiplatelet therapy in patients with atherothrombotic diseases.

Outcomes, Trends, and Predictors of Gastrointestinal Bleeding in Patients Undergoing Transcatheter Aortic Valve Implantation (from the National Inpatient Sample)

Major bleeding has been identified as one of the most common complications after transcatheter aortic valve implantation (TAVI) with some suffering gastrointestinal bleeding (GIB). This study aimed at assessing the incidence and predictors of GIB after TAVI in the United States. We performed a retrospective analysis of data from the National Inpatient Sample database from 2011 to 2018. A total of 216,023 hospitalizations for TAVI were included. Of the included patients, 2,188 (1%) patients had GIB, whereas 213,835 (99%) patients did not have GIB. The presence of arteriovenous malformation was associated with the highest odds of having a gastrointestinal bleed (odds ratio (OR) 24.8, 95% confidence interval (CI) 17.13 to 35.92). Peptic ulcer disease was associated with an eightfold increased risk of bleeding (OR 8.74, 95% CI, 6.69 to 11.43) followed closely by colorectal cancer (OR 7.89, 95% CI, 5.33 to 11.70). Other comorbidities that were associated with higher propensity-matched rates of GIB were chronic kidney disease (OR 1.27,95% CI, 1.14 to 1.41), congestive heart failure (OR 1.18, 95% CI,1.06 to 1.32), liver disease (OR1.83, 95% CI,1.53 to 2.19), end-stage renal disease (OR 2.08,95% CI, 1.75 to 2.47), atrial fibrillation (OR1.63,95% CI,  1.49 to 1.78), and lung cancer (OR 2.80, 95% CI,1.77 to 4.41). Patients with GIB had higher propensity-matched rates of mortality than those without GIB, (12.1% vs 3.2%, p <0.01). Patients with GIB had a higher median cost of stay ($68,779 vs $46,995, p <0.01) and a longer length of hospital stay (11 vs 3 days, p <0.01). In conclusion, health care use and mortality are higher in hospitalizations of TAVI with a GIB. Baseline comorbidities like peptic ulcer disease, chronic kidney disease, liver disease, atrial fibrillation and, colorectal cancer are significant predictors of this adverse event.

Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in Elderly Patients Undergoing Percutaneous Coronary Intervention: A Cohort Study

Background

Age is a strong predictor of adverse outcomes due both to a higher risk of bleeding and ischemia. The purpose of this study was to evaluate the safety and efficacy of ticagrelor in elderly patients.

Methods

Patients ≥75 years of age admitted to our center from January, 2015 to December, 2019 who had undergone percutaneous coronary intervention (PCI) and received dual antiplatelet therapy (DAPT) were included in our study. Eligible patients were divided into clopidogrel and ticagrelor groups according to the P2Y₁₂ receptor inhibitor and were followed up for 1 year. The primary safety endpoint was types 2, 3, and 5 bleeding, as defined by Bleeding Academic Research Consortium (BARC), and the primary efficacy endpoint was combined major adverse cardiovascular and cerebrovascular events (MACCEs). A Cox proportional hazard model and propensity score matching were used to correct confounding factors.

Results

Of 1505 patients enrolled in this study, 442 were assigned to ticagrelor group and 1063 were assigned to clopidogrel group. The incidence of BARC 2, 3, and 5 bleeding (HR, 2.304; 95% CI, 1.540–3.447), and any bleeding (HR, 2.476; 95% CI, 1.802–3.403) in ticagrelor group was significantly higher than clopidogrel group. There were no significant difference between the two groups with respect to BARC 3 and 5 bleeding (HR, 1.566; 95% CI, 0.767–3.198) and MACCEs (HR, 0.957; 95% CI, 0.702–1.305).

Conclusion

Compared with clopidogrel, DAPT with ticagrelor significantly increased the risk of BARC 2, 3, and 5 bleeding without reducing MACCEs in elderly patients who underwent PCI.

Trial Registration

The study was retrospectively registered in clinicaltrials.gov (NCT 04999293).

Prasugrel Dose De-escalation Therapy After Complex Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: A Post Hoc Analysis From the HOST-REDUCE-POLYTECH-ACS Trial

Importance

De-escalation of dual-antiplatelet therapy through dose reduction of prasugrel improved net adverse clinical events after acute coronary syndrome (ACS), mainly through the reduction of bleeding without an increase in ischemic outcomes. However, whether such benefits are similarly observed in those receiving complex procedures is unknown.

Objective

To investigate whether the benefits of prasugrel dose de-escalation therapy are maintained in the complex percutaneous coronary intervention (PCI) subgroup.

Design, Setting, and Participants

This was a post hoc analysis of the HOST-REDUCE-POLYTECH-ACS trial, a randomized, open-label, adjudicator-blinded, multicenter trial performed at 35 hospitals in South Korea. Study participants included patients with ACS who were receiving PCI. Data were collected from September 30, 2014, to December 18, 2015, and analyzed from September 17, 2020, to June 15, 2021.

Interventions and Exposures

Patients were randomized to a prasugrel dose de-escalation (5 mg daily) at 1 month post-PCI group or a conventional (10 mg daily) group. Complex PCI was defined as having at least 1 of the following features: 3 or more stents implanted, 3 or more lesions treated, bifurcation PCI, total stent length 60 mm or larger, left main PCI, or heavy calcification.

Main Outcomes and Measures

The main analysis end points were MACE (major adverse cardiac event, a composite of cardiovascular death, nonfatal myocardial infarction, stent thrombosis, and repeat revascularization) at 1 year for ischemic outcomes, and BARC (Bleeding Academic Research Consortium) class 2 or higher bleeding events at 1 year for bleeding outcomes.

Results

Of 2271 patients (mean [SD] age, 58.9 [9.0] years; 2024 [89%] male patients) for whom full procedural data were available, 705 patients received complex PCI, and 1566 patients received noncomplex PCI. Complex PCI was associated with higher rates of ischemic outcomes but not with bleeding outcomes. Prasugrel dose de-escalation did not increase the risk of MACE (hazard ratio [HR], 0.88; 95% CI, 0.47-1.66; P = .70 in complex PCI; HR, 0.81; 95% CI, 0.45-1.46; P = .48 in noncomplex PCI; P for interaction = .84) but decreased BARC class 2 or higher bleeding events (HR, 0.25; 95% CI, 0.10-0.61; P = .002 in complex PCI; HR, 0.62; 95% CI, 0.38-1.00; P = .05 in noncomplex PCI; P for interaction = .08), albeit with wide 95% CIs.

Conclusions and Relevance

In this post hoc analysis of patients with ACS, prasugrel dose de-escalation compared with conventional therapy was not associated with an increased risk of ischemic outcomes but may reduce the risk of minor bleeding events at 1 year, irrespective of PCI complexity.

Trial Registration

ClinicalTrials.gov Identifier: NCT02193971.

Dual Loading Antiplatelet Therapy in Patients With Acute Coronary Syndrome and High Bleeding Risk Undergoing Percutaneous Coronary Intervention: Findings From the Improving Care for Cardiovascular Disease in China Project

Objective

Loading dose of dual antiplatelet therapy (LD) is supported by the guidelines for patients with acute coronary syndrome (ACS). However, limited data is provided in the series of high bleeding risk (HBR) patients with ACS and percutaneous coronary intervention (PCI).

Methods

Using data from the Improving Care for Cardiovascular Disease in China—Acute Coronary Syndrome registry, conducted between 2014 and 2019, we stratified all ACS patients with HBR and PCI according to LD used within 24 h of first medical contact or not. Inverse probability of treatment weighting (IPTW) and Cox proportional hazards model with hospital as random effect were used to analyze differences in in-hospital clinical outcomes: the primary efficacy endpoint was mortality, and the primary safety endpoint was bleeding.

Results

Of 21,654 evaluable patients 14,322 (66.2%) were treated with LD, and were on average older, less likely to have comorbidities and higher hemoglobin, more often treated GPI and anticoagulant during hospitalization than those without LD. After IPTW adjustment for baseline differences, LD was associated with significantly increased risk of in-hospital mortality [1.89 vs. 1.02%; hazard ratio (HR): 1.71 (95% confidence interval 1.12, 2.42); p &lt; 0.001] and in-hospital bleeding [3.89 vs. 3.3%; HR: 1.25 (1.03, 1.53); p = 0.03].

Conclusions

In ACS patients with HBR, LD was associated with an increased risk of in-hospital mortality and bleeding complications after PCI. Dedicated randomized trials with contemporary ACS management are needed to confirm these findings.

Trade-off of major bleeding versus myocardial infarction on mortality after percutaneous coronary intervention

Background

The choice of antithrombotic therapy after percutaneous coronary intervention (PCI) is heavily dependent on the relative trade-off between major bleeding (MB) and myocardial infarction (MI). However, the mortality trade-off was mostly described in Western populations and remained unknown in East Asians.

Method

This was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between 2004 and 2017. Participants were patients undergoing first-time PCI and survived for the first year. Patients were stratified by the presence of MB and MI during the first year. The primary endpoint was all-cause mortality between 1 and 5 years after PCI. The secondary endpoint was cardiovascular mortality.

Results

A total of 32 180 patients were analysed. After adjustment for baseline characteristics and using patients with neither events as reference, the risks of all-cause mortality were increased in patients with MI only (HR, 1.63; 95% CI 1.45 to 1.84; p<0.001), further increased in those with MB only (HR, 2.11, 95% CI 1.86 to 2.39; p<0.001) and highest in those with both (HR, 2.92; 95% CI 2.39 to 3.56; p<0.001). In both Cox regression and propensity score analyses, MB had a stronger impact on all-cause mortality than MI, but similar impact on cardiovascular mortality.

Conclusions

Both MB and MI within the first year after PCI were associated with increase in all-cause and cardiovascular mortality in Chinese patients, but the impact was stronger with MB.

Antiplatelet Therapy and Bleeding Outcomes With CYP2C19 Genotyping

PURPOSE

The impact of antiplatelet therapy with availability of CYP2C19 genotyping on bleeding in a real-world setting has not been extensively studied.

METHODS

Prospective, single-center, cohort study conducted between December 2015 and October 2019 with 1-year follow-up. Patients underwent percutaneous coronary intervention (PCI), CYP2C19 genotyping, and received P2Y12 inhibitor therapy. The primary outcome was time to first bleed of any severity using Bleeding Academic Research Consortium criteria. Secondary outcomes included time to first major bleed and rates of antiplatelet switching.

RESULTS

The primary outcome occurred in 697 of 2091 (33%) participants at a median of 15 days. Major bleeding occurred in 176 (8%) of patients. Compared to clopidogrel, treatment with ticagrelor or prasugrel was associated with increased risk of any bleeding (adjusted HR [aHR] 2.04, 95% CI 1.69-2.46). For patients without CYP2C19 no function alleles, treatment with prasugrel or ticagrelor was associated with increased risk of any bleeding (aHR 2.31, 95% CI 1.83-2.90). Similar associations were observed for major bleeding. No difference in ischemic events was observed. Among patients discharged on ticagrelor or prasugrel, 199 (36%) were de-escalated to clopidogrel within 1 year. De-escalation was more likely after a bleed if patients did not have a no function allele (35.9% vs 19.1%; P = .02).

CONCLUSION

Bleeding is common in post-PCI patients on antiplatelet therapy. Patients on high potency agents had higher bleeding risk in the population at-large and in non-carriers of CYP2C19 no function alleles. Genotype-guided antiplatelet de-escalation should be further explored in prospective studies.

Atrial Fibrillation and Coronary Artery Disease: A Long-Term Perspective on the Need for Combined Antithrombotic Therapy

BACKGROUND

Older adults with atrial fibrillation (AF) are often treated with the shortest possible duration of antiplatelet/anticoagulant therapy after myocardial infarction (MI) or percutaneous coronary intervention (PCI) due to concern for bleeding. However, the risk of recurrent MI or PCI prompting antiplatelet therapy extension is unknown in this population.

METHODS

Using the National Cardiovascular Data Registry linked to Medicare claims, we described the cumulative incidence of recurrent MI or PCI over a median of 7-year follow-up for patients ≥65 years old with AF discharged alive after acute MI between 2008 and 2017. We used pharmacy fill data to describe the proportion of patients filling prescriptions for both oral anticoagulants and P2Y₁₂ inhibitors for ≥50% of the indicated duration after MI or PCI.

RESULTS

Of 187 622 older patients discharged alive after MI, 50 539 (26.9%) had AF. Over a median of 7-year follow-up in patients with AF, the cumulative incidence was 14.5% for recurrent MI, 12.1% for PCI, 7.9% for stroke, and 9.5% for bleeding hospitalization. Among 7998 patients with AF and recurrent MI or PCI, 1668 (20.9%) had >1 MI or PCI during follow-up. Assuming each MI or PCI should be followed by 6 months of P2Y₁₂ inhibitor therapy, patients with AF who had a recurrent MI/PCI had a median estimated indication for antiplatelet/anticoagulant treatment of 287 days (194, 358), but filled both P2Y₁₂ inhibitor and oral anticoagulant for a median of 0 days (0, 21). In this cohort, 12.2% of patients filled prescriptions for both a P2Y₁₂ inhibitor and oral anticoagulant for ≥50% of the indicated duration.

CONCLUSIONS

Older adults with AF and MI have high incidences of downstream recurrent MI or PCI requiring extended antiplatelet/anticoagulant therapy durations, yet many appear to be under-treated. These results highlight the need for better thrombosis prevention strategies in this group of patients.

Trends in Bleeding Events Among Patients With Acute Coronary Syndrome in China, 2015 to 2019: Insights From the CCC-ACS Project

Objective: Major bleeding is a common complication following treatment for an acute coronary syndrome (ACS) and is associated with increased mortality. We aimed to explore the temporal trend of bleeding events in relation to changes of therapeutic strategies among patients hospitalized for ACS in China. Methods: The CCC-ACS project (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) is a collaborative initiative of the American Heart Association and the Chinese Society of Cardiology. We analyzed 113,567 ACS patients from 241 hospitals in China from 2015 to 2019. Major bleeding was defined as intracranial bleeding, retroperitoneal bleeding, a decline in hemoglobin levels ≥3 g/dL, transfusion with overt bleeding, bleeding requiring surgical intervention, and fatal bleeding. Kruskal-Wallis test was used to examine the trend of major bleeding over time. Results: The rate of in-hospital major bleeding decreased from 6.3% in 2015 to 4.7% in 2019 (unadjusted OR = 0.74, 95% CI: 0.68-0.80, and P < 0.001). The relative changes were consistent across almost all subgroups including patients with NSTE-ACS and STEMI, although the trend was more pronounced in NSTE-ACS patients. The decrease in bleeding was accompanied by a decrease in use of GP IIb/IIIa inhibitors and parenteral anticoagulation therapy during hospitalization. The annual reduced risk of bleeding (OR = 0.91, 95% CI: 0.89-0.93) was attenuated after stepwise adjusting for baseline characteristics and antithrombotic treatments (OR = 0.95, 95% CI: 0.93-0.97), but did not change after adjusting for invasive treatment (OR = 0.95, 95% CI: 0.93-0.97). Conclusions: There was a temporal reduction in in-hospital bleeding among Chinese ACS patients during the last 5 years, which was associated with more evidence-based use of antithrombotic therapies. Clinical Trial Registration: https://www.clinicaltrials.gov, identifier: NCT02306616.