Meta-analysis of intracranial hemorrhage in acute coronary syndromes: incidence, predictors, and clinical outcomes

Intracranial Hemorrhage in Hospitalized Patients Following Percutaneous Coronary Intervention: A Large Cohort Analysis from a Single Center

BACKGROUND

There are several reports on the prevalence and characteristics of intracranial hemorrhage (ICH) following percutaneous coronary intervention (PCI), which is a rare but severe complication with high mortality. However, the clinical landscapes of computed tomography (CT)-confirmed, symptomatic ICH in hospitalized patients are not fully characterized.

METHODS

Among 121,066 patients receiving PCI treatment in the Fu Wai Hospital between 2013 and 2022, there were 18 CT-defined, symptomatic patients with ICH occurring during post-PCI hospitalization. Symptomatic ICH was defined as clinical suspicion of hemorrhage and/or new focal neurological signs. We analyzed ICH timing, clinical and imaging features, and subsequent outcomes.

RESULTS

Overall, in this retrospective analysis, the incidence of CT-defined, symptomatic ICH was 0.015% (18/121,066). More than half of the cases (55.6%) occurred within the first 12 h following PCI. The most common initial manifestation of ICH patients was disturbance of consciousness. Thirteen patients (72.2%) had a hematoma volume ≥ 30 cm³. Additionally, the ICH was observed in the cerebral lobe (66.7%), cerebellum (22.2%), and the basal ganglia and thalamus (11.1%). The 90-day mortality of ICH patients undergoing PCI was very high (72.2%). Consciousness disturbance (p = 0.036), intracerebral hemorrhage volume > 30 mm³ (p = 0.001), and intracerebral hemorrhage originating from the infratentorial origin (p = 0.044) were significantly higher in patients who died.

CONCLUSIONS

Symptomatic ICH events occur with a rate of around 0.015%, with significantly higher short-term mortality risk in our cohort receiving PCI, which has not yet been demonstrated in other cohorts.

Long-term outcomes after traumatic brain injury in elderly patients on antithrombotic therapy

INTRODUCTION

Elderly patients receiving antithrombotic treatment have a significantly higher risk of developing an intracranial hemorrhage when suffering traumatic brain injury (TBI), potentially contributing to higher mortality rates and worse functional outcomes. It is unclear whether different antithrombotic drugs carry a similar risk.

OBJECTIVE

This study aims to investigate injury patterns and long-term outcomes after TBI in elderly patients treated with antithrombotic drugs.

METHODS

The clinical records of 2999 patients ≥ 65 years old admitted to the University Hospitals Leuven (Belgium) between 1999 and 2019 with a diagnosis of TBI, spanning all injury severities, were manually screened.

RESULTS

A total of 1443 patients who had not experienced a cerebrovascular accident prior to TBI nor presented with a chronic subdural hematoma at admission were included in the analysis. Relevant clinical information, including medication use and coagulation lab tests, was manually registered and statistically analyzed using Python and R. In the overall cohort, 418 (29.0%) of the patients were treated with acetylsalicylic acid before TBI, 58 (4.0%) with vitamin K antagonists (VKA), 14 (1.0%) with a different antithrombotic drug, and 953 (66.0%) did not receive any antithrombotic treatment. The median age was 81 years (IQR = 11). The most common cause of TBI was a fall accident (79.4% of the cases), and 35.7% of the cases were classified as mild TBI. Patients treated with vitamin K antagonists had the highest rate of subdural hematomas (44.8%) (p = 0.02), hospitalization (98.3%, p = 0.03), intensive care unit admissions (41.4%, p < 0.01), and mortality within 30 days post-TBI (22.4%, p < 0.01). The number of patients treated with adenosine diphosphate (ADP) receptor antagonists and direct oral anticoagulants (DOACs) was too low to draw conclusions about the risks associated with these antithrombotic drugs.

CONCLUSION

In a large cohort of elderly patients, treatment with VKA prior to TBI was associated with a higher rate of acute subdural hematoma and a worse outcome, compared with other patients. However, intake of low dose aspirin prior to TBI did not have such effects. Therefore, the choice of antithrombotic treatment in elderly patients is of utmost importance with respect to risks associated with TBI, and patients should be counselled accordingly. Future studies will determine whether the shift towards DOACs is mitigating the poor outcomes associated with VKA after TBI.

Prehospital misdiagnosis of acute cerebral disease for acute coronary syndrome: a retrospective study

OBJECTIVE

In cerebrovascular accidents symptoms, laboratory results and electrocardiogram (ECG) changes can mimic acute coronary syndrome (ACS) and is subsumed as neurogenic stunned myocardium. So far, data regarding the frequency of cerebrovascular accidents misdiagnosed for ACS in a prehospital setting are missing. This study aims to quantify misdiagnoses and discover discriminating features.

METHODS

In a retrospective cohort study, prehospital and hospital medical records of all patients treated by physician-staffed emergency medical teams in the city of Bonn (Germany) with suspected ACS in 2018 were evaluated regarding medical history, prehospital symptoms and findings as well as hospital diagnoses.

RESULTS

From 758 patients admitted for presumed ACS, 9 patients (1.2%, 95% CI: 0.5-2.2%) suffered from acute cerebral disease (ACD group). Mainly, diagnoses were cerebrovascular accidents and one case of neuroborreliosis. A history of intracranial haemorrhage was found more often in the ACD group compared to the remaining cohort (OR 19, p = 0.01), while a history of arterial hypertension was less frequent (OR 0.22, p = 0.03). Presentation with headaches (OR 10.1, p = 0.03) or neurological symptoms (OR 16.9, p = 0.01) occurred more frequent in the ACD group. ECG changes were similar between groups.

CONCLUSION

Acute cerebral disease misdiagnosed for ACS seems more common than assumed. Out of 758 patients with presumed ACS, 9 patients (1.2%) suffered from ACD, which were cerebrovascular accidents mainly. This is highly relevant, since prehospital treatment with heparin and acetylsalicylic acid is indicated in ACS but contraindicated in cerebrovascular accidents without further diagnostics. Thus, discriminating these patients is crucial. An attentive patient history and examination may be the key to differentiating ACD. Due to small ACD group size, further studies are needed.

Incidence and predictors of intracranial bleeding after coronary artery bypass graft surgery

Background

There is a paucity of direct data on the incidence and predictors of intracranial bleeding (ICB) after coronary artery bypass graft surgery (CABG).

Methods

The Korean National Health Insurance database was used to identify patients without prior ICB who underwent CABG. The outcomes of interest were the time-dependent incidence rates of ICB and the associated mortality.

Results

Among 35,021 patients who underwent CABG between 2007 and 2018, 895 (2.6%) experienced an ICB during a median follow-up of 6.0 years. The 1-year cumulative incidence of ICB was 0.76%, with a relatively high incidence rate (9.93 cases per 1,000 person-years) within the first 1–30 days. Subsequent incidence rates showed a sharp decline until 3 years, followed by a steady decrease up to 10 years. The 1-year mortality rate after ICB was 38.1%, with most deaths occurring within 30 days (23.6%). The predictors of ICB after CABG were age ≥ 75 years, hypertension, pre-existing dementia, history of ischemic stroke or transient ischemic attack, and end-stage renal disease.

Conclusions

In an unselected nationwide population undergoing CABG, the incidence of ICB was non-negligible and showed a relatively high incidence rate during the early postoperative period. Post-CABG ICB was associated with a high risk of premature death. Further research is needed to stratify high-risk patients and personalize therapeutic decisions for preventing ICB after CABG.

Risk of ischaemic and haemorrhagic stroke in Chinese undergoing percutaneous coronary intervention treated with potent P2Y12 inhibitor versus clopidogrel

Background

Stroke after acute coronary syndrome (ACS) can be devastating. It is uncertain whether the risks of ischaemic stroke or intracranial haemorrhage (ICH) are associated with different choices of P2Y12 inhibitors (potent P2Y12 inhibitors such as ticagrelor and prasugrel vs clopidogrel). Even though East Asians are known to have different thrombotic and haemorrhagic profiles from Caucasians, data on Chinese patients are sparse.

Method

This was a retrospective cohort study conducting in Chinese patients with ACS who underwent first-ever percutaneous coronary intervention from 14 hospitals in Hong Kong between 2010 and 2017. The primary efficacy endpoint was ischaemic stroke. The secondary efficacy endpoint was a composite outcome of thrombotic events including all-cause mortality, non-fatal myocardial infarction and ischaemic stroke. The primary safety endpoint was ICH. The secondary safety endpoint was a composite of major bleeding events.

Results

After adjustment of baseline characteristics by 1:1 propensity score matching, a total of 6220 patients (3110 on each group) were analysed. Compared with clopidogrel, potent P2Y12 inhibitors were associated with a lower risk of ischaemic stroke (HR 0.57; 95% CI 0.37 to 0.87; p=0.008) and a lower risk of thrombotic events (HR 0.77; 95% CI 0.66 to 0.90; p=0.001). Potent P2Y12 inhibitor was associated with similar risk of ICH (HR 0.65; 95% CI 0.34 to 1.25, p=0.20) and major bleeding (HR 0.83; 95% CI 0.68 to 1.01, p=0.069).

Conclusions

Potent P2Y12 inhibitors were associated with a lower adjusted risk of ischaemic stroke and thrombotic events, compared with clopidogrel. The risks of ICH and major bleeding were similar.

Rationale and Design of the H-REPLACE Study: Safety and Efficacy of LMWH Versus Rivaroxaban in ChinEse Patients HospitaLized with Acute Coronary SyndromE

BACKGROUND

Acute coronary syndrome (ACS) is a serious and life-threatening condition. Anticoagulation during the acute phase of ACS is effective in reducing ischemic events. The most widely used parenteral anticoagulation agent in ACS patients is enoxaparin. Rivaroxaban is a novel oral anticoagulant with potent anti-Xa activity, which might be an attractive alternative drug to enoxaparin. In fact, rivaroxaban was consistently shown to be non-inferior to enoxaparin therapy in terms of reduction of recurrent venous thromboembolism events.

OBJECTIVE

This prospective, randomized, open-label, active-controlled, multicenter study is designed to compare the safety and efficacy of rivaroxaban versus enoxaparin in patients with ACS, who missed the primary reperfusion therapy window and before selective revascularization.

METHODS AND RESULTS

Up to 2055 participants receiving background treatment of aspirin plus clopidogrel or ticagrelor will be randomly assigned to either oral rivaroxaban 2.5 mg twice daily or rivaroxaban 5 mg twice daily or subcutaneous enoxaparin 1 mg/kg twice daily until hospital discharge for a maximum of 8 days or 12 h before revascularization therapy. The primary safety endpoint is the International Society on Thrombosis and Hemostasis definition of bleeding events [minor, clinically relevant non-major and major bleeding]. The primary efficacy endpoint is a composite of major adverse cardiac events (MACE), including cardiac death, myocardial infarction, re-revascularization or stroke, and major bleeding events. Secondary endpoints include cardiac-related rehospitalization and all-cause death. Patients will be followed for 12 months after randomization.

CONCLUSIONS

The H-REPLACE trial offers an opportunity to assess clinical outcomes of rivaroxaban versus enoxaparin during the acute phase of ACS and may provide an alternative anticoagulation strategy for ACS patients, who missed the primary reperfusion therapy window and before selective revascularization.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT03363035.

Intracranial Bleeding After Percutaneous Coronary Intervention: Time-Dependent Incidence, Predictors, and Impact on Mortality

Background

Limited data are available on intracranial hemorrhage (ICH) in patients undergoing antithrombotic therapy after percutaneous coronary intervention (PCI).

Methods and Results

Using the Korean National Health Insurance Service database, we identified 219 274 patients without prior ICH and who underwent a first PCI procedure between 2007 and 2016 and analyzed nontraumatic ICH and all‐cause mortality. ICH after PCI occurred in 4171 patients during a median follow‐up of 5.6 years (overall incidence rate: 3.32 cases per 1000 person‐years). The incidence rate of ICH showed an early peak of 21.66 cases per 1000 person‐years within the first 30 days, followed by a sharp decrease to 3.68 cases per 1000 person‐years between 30 days and 1 year, and to <1 case per 1000 patient‐years from the second year until 10 years after PCI. The 1‐year mortality rate was 38.2% after ICH, with most deaths occurring within 30 days (n=999, mortality rate: 24.2%). No significant difference in mortality risk was observed between patients who had ICH within and after 1 year following PCI (adjusted hazard ratio, 1.04; 95% CI, 0.95–1.14; P=0.43). The predictors of post‐PCI ICH were age ≥75 years, hypertension, atrial fibrillation, end‐stage renal disease, history of stroke or transient ischemic attack, dementia, and use of vitamin K antagonists.

Conclusions

New ICH most frequently occurs in the early period after PCI and is associated with a high risk of early death, regardless of the occurrence time of ICH. Careful implementation of antithrombotic strategies is needed in patients at an increased risk for ICH, particularly in the peri‐PCI period.

Effect of Baseline Thrombocytopenia on Long-Term Outcomes in Patients With Acute ST-Segment Elevated Myocardial Infarction - A Large Propensity Score-Matching Analysis From the China Acute Myocardial Infarction (CAMI) Registry

BACKGROUND

Data on the association of baseline thrombocytopenia (TP) with long-term outcomes of patients with acute ST-segment elevated myocardial infarction (STEMI) are still limited.Methods and Results:A total of 16,957 consecutive cases of patients with STEMI from multiple centers that participated in the China Acute Myocardial Infarction (CAMI) registry were included in this study. Two-year clinical outcomes were evaluated between patients with TP and those with a normal platelet count (PLT). Cases coexisting with baseline TP accounted for 2.1%. The rates of 2-year all-cause death (21.4% and 11.4%, P<0.001) and major adverse cardiovascular and cerebrovascular events (MACCE) (23.6% and 13.9%, P<0.001) were significantly higher in cases with TP, compared with the normal PLT group. After multivariate adjustment, compared with the control, cases with TP were not independently associated with 2-year all-cause death (HR: 1.21; 95% CI: 0.96-1.52; P=0.110) and MACCE (HR: 1.18; 95% CI: 0.95-1.47; P=0.132). After propensity score matching (PSM), the rates of 2-year all-cause death and MACCE were similar between the 2 groups (20.7% and 17.9%, P=0.317; 23.0% and 19.9%, P=0.288). Multivariable adjustment after PSM showed baseline TP was not independently associated with all-cause death (HR: 1.21; 95% CI: 0.88-1.67; P=0.240) and MACCE (HR: 1.21; 95% CI: 0.89-1.63; P=0.226).

CONCLUSIONS

Patients with STEMI and baseline TP had higher rates of all-cause death and MACCE; however, baseline TP was not independently associated with 2-year adverse outcomes in patients with STEMI after multivariate adjustment and controlling for baseline differences.

Incidence, predictors and prognostic impact of intracranial bleeding within the first year after an acute coronary syndrome in patients treated with percutaneous coronary intervention

Background:

The rate of intracranial haemorrhage after an acute coronary syndrome has been studied in detail in the era of thrombolysis; however, in the contemporary era of percutaneous coronary intervention, most of the data have been derived from clinical trials. With this background, we aim to analyse the incidence, timing, predictors and prognostic impact of post-discharge intracranial haemorrhage in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

Methods:

We analysed data from the BleeMACS registry (patients discharged for acute coronary syndrome and undergoing percutaneous coronary intervention from Europe, Asia and America, 2003–2014). Analyses were conducted using a competing risk framework. Uni and multivariate predictors of intracranial haemorrhage were assessed using the Fine–Gray proportional hazards regression analysis. The endpoint was 1-year post-discharge intracranial haemorrhage.

Results:

Of 11,136 patients, 30 presented with intracranial haemorrhage during the first year (0.27%). The median time to intracranial haemorrhage was 150 days (interquartile range 55.7–319.5). The fatality rate of intracranial haemorrhage was very high (30%). After multivariate analysis, only age (subhazard ratio 1.05, 95% confidence interval 1.01–1.07) and prior stroke/transient ischaemic attack (hazard ratio 3.29, 95% confidence interval 1.36–8.00) were independently associated with a higher risk of intracranial haemorrhage. Hypertension showed a trend to associate with higher intracranial haemorrhage rate. The combination of older age (⩾75 years), prior stroke/transient ischaemic attack, and/or hypertension allowed us to identify most of the patients with intracranial haemorrhage (86.7%). The annual rate of intracranial haemorrhage was 0.1% in patients with no risk factors, 0.2% in those with one factor, 0.6% in those with two factors and 1.3% in those with three factors.

Conclusion:

The incidence of intracranial haemorrhage in the first year after an acute coronary syndrome treated with percutaneous coronary intervention is low. Advanced age, previous stroke/transient ischaemic attack, and hypertension are the main predictors of increased intracranial haemorrhage risk.

Intracranial Hemorrhage Complicating Acute Myocardial Infarction: An 18-Year National Study of Temporal Trends, Predictors, and Outcomes

BACKGROUND

There is a paucity of contemporary data on the burden of intracranial hemorrhage (ICH) complicating acute myocardial infarction (AMI). This study sought to evaluate the temporal trends, predictors, and outcomes of ICH in AMI.

METHODS

The National Inpatient Sample (2000-2017) was used to identify adult (>18 years) AMI admissions with ICH. In-hospital mortality, hospitalization costs, length of stay, and measure of functional ability were the outcomes of interest. The discharge destination along with use of tracheostomy and percutaneous endoscopic gastrostomy were used to estimate functional burden.

RESULTS

Of a total 11,622,528 AMI admissions, 23,422 (0.2%) had concomitant ICH. Compared to those without, the ICH cohort was on average older, female, of non-White race, had greater comorbidities, and had higher rates of arrhythmias (all p < 0.001). Female sex, non-White race, ST-segment elevation AMI presentation, use of fibrinolytics, mechanical circulatory support, and invasive mechanical ventilation were identified as individual predictors of ICH. The AMI admissions with ICH received less frequent coronary angiography (46.9% vs. 63.8%), percutaneous coronary intervention (22.7% vs. 41.8%), and coronary artery bypass grafting (5.4% vs. 9.2%), as compared to those without (p < 0.001). ICH was associated with a significantly higher in-hospital mortality (41.4% vs. 6.1%; adjusted OR 5.65 (95% CI 5.47-5.84); p < 0.001), longer hospital length of stay, higher hospitalization costs, and greater use of percutaneous endoscopic gastrostomy (all p < 0.001). Among ICH survivors (N = 13, 689), 81.3% had a poor functional outcome at discharge.

CONCLUSIONS

ICH causes a substantial burden in AMI due to associated higher in-hospital mortality and poor functional outcomes.

Stroke Outcomes With Vorapaxar Versus Placebo in Patients With Acute Coronary Syndromes: Insights From the TRACER Trial

Background

Vorapaxar, a protease‐activated receptor‐1 antagonist, is approved for secondary prevention of cardiovascular events but is associated with increased intracranial hemorrhage.

Methods and Results

TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) was a trial of vorapaxar versus placebo among patients with acute coronary syndrome. Strokes were adjudicated by a central events committee. Of 12 944 patients, 199 (1.5%) had ≥1 stroke during the study period (median follow‐up, 477 days). Four patients had a single stroke of unknown type; 195 patients had ≥1 stroke classified as hemorrhagic or nonhemorrhagic (165 nonhemorrhagic, 28 hemorrhagic, and 2 both). Strokes occurred in 96 of 6473 patients (1.5%) assigned vorapaxar and 103 of 6471 patients (1.6%) assigned placebo. Kaplan‐Meier incidence of stroke for vorapaxar versus placebo was higher for hemorrhagic stroke (0.45% versus 0.14% [hazard ratio, 2.74; 95% confidence interval, 1.22–6.15]), lower but not significantly different for nonhemorrhagic stroke (1.53% versus 1.98% at 2 years [hazard ratio, 0.79; 95% confidence interval, 0.58–1.07]), and similar for stroke overall (1.93% versus 2.13% at 2 years [hazard ratio, 0.94; 95% confidence interval, 0.71–1.24]).

Conclusions

Stroke occurred in <2% of patients. Vorapaxar‐assigned patients had increased hemorrhagic stroke but a nonsignificant trend toward lower nonhemorrhagic stroke. Overall stroke frequency was similar with vorapaxar versus placebo.

Efficacy and Safety of the Use of Non-vitamin K Antagonist Oral Anticoagulants in Patients with Ischemic Heart Disease: A Meta-Analysis of Phase III Randomized Trials

BACKGROUND

There are conflicting published data on non-vitamin K antagonist oral anticoagulants (NOACs), with varying evidence of benefit or harm in acute coronary syndrome (ACS) and non-ACS cohorts. To explore the efficacy and safety of NOAC use in patients with ischemic heart disease (IHD), we conducted a meta-analysis of phase III randomized controlled trials (RCTs).

METHODS

We systematically searched the Cochrane Library, PubMed, and Embase databases. A random-effect model was selected to pool the effect measurement estimates (hazard ratios [HRs] and 95% confidence intervals [CIs]).

RESULTS

Three RCTs with 39,492 enrolled IHD patients were included. Compared with placebo, NOACs were associated with reduced risks of major adverse cardiac events (MACE) (HR 0.83, 95% CI 0.76-0.90), cardiovascular death (HR 0.82, 95% CI 0.72-0.93), and myocardial infarction (HR 0.87, 95% CI 0.78-0.97) accompanied by increased risks of major bleeding (HR 2.46, 95% CI 1.42-4.26), but not fatal bleeding (HR 1.35, 95% CI 0.76-2.39) or intracranial hemorrhage (HR 2.19, 95% CI 0.91-5.27). Subgroup analysis revealed that NOACs were associated with an increased risk of major bleeding in patients who received dual antiplatelet therapy compared with patients who received single antiplatelet therapy (3.01, 1.82-4.98 vs. 1.66, 1.37-2.03; P for interaction 0.03) and patients with ACS compared with patients with non-ACS (3.27, 2.16-4.95 vs. 1.66, 1.36-2.02; P for interaction 0.004).

CONCLUSIONS

In patients with IHD, NOACs confer protection against thrombosis-related complications, but at the cost of an increased hazard of major bleeding. NOACs plus a single antiplatelet drug seem to be a good choice for patients with IHD.

Impact of Cerebrovascular Events Older Than One Year on Ischemic and Bleeding Outcomes With Cangrelor in Percutaneous Coronary Intervention

BACKGROUND

Cangrelor is a potent intravenous adenosine diphosphate-receptor antagonist that in the CHAMPION trials reduced the 48-hour and 30-day rates of ischemic events during percutaneous coronary intervention without an increase in severe bleeding.

METHODS AND RESULTS

CHAMPION PCI (A Clinical Trial to Demonstrate the Efficacy of Cangrelor), CHAMPION PLATFORM (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition), and CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) were 3 randomized, double-blind, double-dummy trials in which cangrelor was compared with clopidogrel during percutaneous coronary intervention. The effect of cangrelor on ischemic events and bleeding was analyzed in the subgroup of patients with a history of cerebrovascular events at least 1 year prior to randomization; the Breslow-Day test was used to test for interaction of treatment effect in subgroups with and without such a history. The primary efficacy end point was a composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 hours. Among 24 910 randomized patients, 1270 patients (5.1%) had a cerebrovascular event >1 year old, including 650 assigned to cangrelor and 620 assigned to clopidogrel. Consistent with the overall trial results, the rate of the primary efficacy end point was 4.3% in the cangrelor group versus 5.3% in the clopidogrel group (odds ratio 0.80; 95% confidence interval 0.48-1.34; P=0.40; P for interaction =0.97), and the rate of GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) severe bleeding was 0.3% in both groups (P=0.97; P for interaction =0.81).

CONCLUSIONS

Among patients in the CHAMPION trials with a prior cerebrovascular event at least 1 year before the percutaneous coronary intervention, the efficacy and bleeding profile of cangrelor compared with clopidogrel was similar to that in the overall trial.

Differential occurrence, profile, and impact of first recurrent cardiovascular events after an acute coronary syndrome

OBJECTIVE

Acute coronary syndrome (ACS) trials typically use a composite primary outcome (myocardial infarction [MI], stroke, or cardiovascular death), but differential patient characteristics, timing, and consequences associated with individual component end points as first events have not been well studied. We compared patient characteristics and prognostic significance associated with first cardiovascular events in the post-ACS setting for initially stabilized patients.

METHODS

We combined patient-level data from 4 trials of post-ACS antithrombotic therapies (PLATO, APPRAISE-2, TRACER, and TRILOGY ACS) to characterize the timing of and characteristics associated with first cardiovascular events (MI, stroke, or cardiovascular death). Landmark analysis at 7 days after index ACS presentation was used to focus on spontaneous, postdischarge events that were not confounded by in-hospital procedural complications. Using a competing risk framework, we tested for differential associations between prespecified covariates and the occurrence of nonfatal stroke vs MI as the first event, and we examined subsequent events after the first nonfatal event.

RESULTS

Among 46,694 patients with a median follow-up of 358 (25th, 75th percentiles 262, 486) days, a first ischemic event occurred in 4,307 patients (9.2%) as follows: MI in 5.8% (n = 2,690), stroke in 1.0% (n = 477), and cardiovascular death in 2.4% (n = 1,140). Older age, prior stroke/transient ischemic attack, prior atrial fibrillation, and higher diastolic blood pressure were associated with a significantly greater risk of stroke vs MI, whereas prior percutaneous coronary intervention was associated with a greater risk of MI vs stroke. Second events occurred in 32% of those with a first nonfatal stroke at a median of 13 (3, 59) days after the first event and in 32% of those with a first nonfatal MI at a median of 35 (5, 137) days after the first event. The most common second event was a recurrent MI among those with MI as the first event and cardiovascular death among those with stroke as the first event.

CONCLUSIONS

Approximately 9% of patients experienced a first cardiovascular event in the post-ACS setting during a median follow-up of 1 year. Although the profile and prognostic implications of stroke vs MI as the first nonfatal event differ substantially, approximately one-third of these patients experienced a second event, typically soon after the first event. These findings have implications for improving post-ACS care and influencing the design of future cardiovascular trials.

Predictors of long-term outcomes after bypass grafting versus drug-eluting stent implantation for left main or multivessel coronary artery disease

BACKGROUND

We assessed predictors of long-term outcomes after coronary artery bypass grafting (CABG) versus those after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in 3,230 patients with left main or multivessel coronary artery disease (CAD).

METHODS AND RESULTS

Data were pooled from the BEST, PRECOMBAT, and SYNTAX trials. Age, chronic kidney disease, chronic obstructive lung disease, left ventricular dysfunction, and peripheral arterial disease (PAD) were common predictors of all-cause mortality. Diabetes mellitus, previous myocardial infarction (MI), and SYNTAX score were independent predictors of all-cause mortality in the PCI group, but not in the CABG group. In the CABG group, age was the only risk factor for MI; left ventricular dysfunction, hypertension, and PAD were risk factors for stroke. On the other hand, in the PCI group, incomplete revascularization and previous MI were risk factors for MI; age and previous stroke for stroke. In addition, chronic kidney disease significantly correlated with a composite outcome of death, MI, or stroke in the CABG group, and incomplete revascularization and previous MI in the PCI group.

CONCLUSIONS

Simple clinical variables and SYNTAX score differentially predict long-term outcomes after CABG versus those after PCI with DES for left main or multivessel CAD. Those predictors might help to guide the choice of revascularization strategy. © 2017 Wiley Periodicals, Inc.

Age is not associated with intracranial haemorrhage in patients with mild traumatic brain injury and oral anticoagulation

Background

Patients admitted to emergency departments with traumatic brain injury (TBI) are commonly being treated with oral anticoagulants. In contrast to patients without anticoagulant medication, no guidelines, scores or recommendations exist for the management of mild traumatic brain injury in these patients. We therefore tested whether age as one of the high risk factors of the Canadian head CT rule is applicable to a patient population on oral anticoagulants.

Methods

This cross-sectional analysis included all patients with mild TBI and concomitant oral anticoagulant therapy admitted to the Emergency Department, Inselspital Bern, Switzerland, from November 2009 to October 2014 (n = 200). Using a logistic regression model, two groups of patients with mild TBI on oral anticoagulant therapy were compared — those with and those without intracranial haemorrhage.

Results

There was no significant difference in age between the patient groups with (n = 86) and without (n = 114) intracranial haemorrhage (p = 0.078).

In univariate logistic regression, GCS (OR = 0.419 (0.258; 0.680)) and thromboembolic event as reason for anticoagulant therapy (OR = 0.486 (0.257; 0.918)) were significantly associated with intracranial haemorrhage in patients with mild TBI and anticoagulation (all p < 0.05). However, there was no association with age (p = 0.078, OR = 1.024 (0.997; 1.051)), the type of accident or additional medication with acetylsalicylic acid or clopidogrel ((both p > 0.05; 0.552 (0.139; 2.202) and 0.256 (0.029; 2.237), respectively).

Conclusion

Our study found no association between age and intracranial bleeding. Therefore, until further risk factors are identified, diagnostic imaging with CCT remains necessary for mild TBI patients on oral anticoagulation of all ages, especially those with therapeutic anticoagulation because of thromboembolic events.