Effects of Baseline Thrombocytopenia on In-hospital Outcomes in Patients Undergoing Elective Percutaneous Coronary Intervention

Aspirin use and bleeding events during thrombocytopenia after autologous stem-cell transplantation for multiple myeloma

Background

In patients with cardiovascular (CV) comorbidities that necessitate antiplatelet therapy (APT), its optimal management during chemotherapy-induced thrombocytopenia remains elusive, as the risk of bleeding has to be balanced against the risk of CV events. The purpose of this study was to assess the risk for bleeding with APT during thrombocytopenia in patients with multiple myeloma undergoing high-dose chemotherapy and subsequent autologous stem-cell transplantation (ASCT) with and without acetylsalicylic acid (ASA) as comedication.

Methods

We assessed patients who underwent ASCT at the Heidelberg University Hospital between 2011 and 2020 for bleeding events, management strategies for ASA intake during thrombocytopenia, transfusion requirements, and the occurrence of CV events.

Results

There were 57/1,113 patients who continued ASA until at least 1 day after ASCT; thus, a continuous platelet inhibition during thrombocytopenia was assumed. Most of the patients (41/57) continued ASA until they had a platelet count of 20-50/nl. This range reflects the kinetics of thrombocytopenia and nondaily measurements of platelets during ASCT. A tendency toward a higher risk for bleeding events in the ASA group was demonstrated (1.9% (control group) vs. 5.3% (ASA), p = 0.082). The risk factors for bleeding in multivariate analysis were the duration of thrombocytopenia < 50/nl, a history of gastrointestinal bleeding, and diarrhea. The factors predicting the duration of thrombocytopenia were age >60 years, a hematopoietic stem-cell transplantation comorbidity index ≥3, and an impaired bone marrow reserve at admission. CV events occurred in three patients; none of them took ASA or had an indication for APT.

Conclusions

The intake of ASA until thrombocytopenia with a platelet count of 20-50/nl appears safe, although an elevated risk cannot be excluded. If ASA is indicated for the secondary prevention of CV events, the evaluation of risk factors for bleeding and a prolonged time of thrombocytopenia before conditioning is crucial to adapt the strategy for ASA intake during thrombocytopenia.

EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer

In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.

Impact of severity of baseline thrombocytopenia on outcomes after percutaneous coronary interventions: Analysis from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) Program

OBJECTIVES

The aim of this study was to evaluate the effect of the degree of severity of baseline thrombocytopenia (TCP) on outcomes after percutaneous coronary intervention (PCI) BACKGROUND: The association of TCP with clinical outcomes among patients undergoing coronary intervention has not been previously evaluated.

METHODS

Using data from the US Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program, we identified patients undergoing PCI between October 1, 2007, to September 30, 2017. The cohort was then stratified by platelet count, as no TCP (platelet count >150,000/mcl), mild TCP (100-150,000/mcl), or moderate-severe TCP (<100,000/mcl) and this was associated with clinical outcomes.

RESULTS

The cohort included 80,427 patients (98% male), of which 14.9% (13.2% mild, 1.7% moderate-severe) suffered from TCP at the time of PCI. Compared with mild or no TCP, moderate-severe TCP was associated with increased risk of post-PCI pericardiocentesis (0.6% vs. 0.2% vs. 0.2%, p = 0.018) and in-hospital mortality (1.5% vs. 0.7% vs. 0.7%) without a difference in postprocedure stroke (0.5% vs. 0.3% vs. 0.3%, p = 0.6). Over a median follow-up of 1729 days, time-to-repeat revascularization was significantly shorter in moderate-severe TCP (1080 vs. 1347 vs. 1467 days, p < 0.001) despite lower risk of revascularization. Both mild (adjusted HR: 1.11, 95% CI: 1.07-1.15, p < 0.001) and moderate-severe TCP (HR: 1.55, 95% CI: 1.43-1.69, p < 0.001) were associated with increased all-cause mortality compared with those without TCP.

CONCLUSIONS

Thrombocytopenia was associated with increased short- and long-term adverse events among patients undergoing PCI. Any degree of TCP was associated with increased long-term all-cause mortality while moderate-severe TCP was also associated with increased risk of periprocedural adverse events.

Development of a Clinical Risk Score for Prediction of Life-Threatening Arrhythmia Events in Patients with ST Elevated Acute Coronary Syndrome after Primary Percutaneous Coronary Intervention

ST-elevated acute coronary syndrome (STEACS) is a serious condition requiring timely treatment. Reperfusion with primary percutaneous coronary intervention (pPCI) is recommended and preferred over fibrinolysis. Despite its efficacy, lethal complications, such as life-threatening arrhythmia (LTA), are common in post-PCI patients. Although various risk assessment tools were developed, only a few focus on LTA prediction. This study aimed to develop a risk score to predict LTA events after pPCI. A risk score was developed using a retrospective cohort of consecutive patients with STEACS who underwent pPCI at Chiangrai Prachanukroh Hospital from January 2012 to December 2016. LTA is defined as the occurrence of malignant arrhythmia that requires advanced cardiovascular life support (ACLS) within 72 h after pPCI. Logistic regression was used for model derivation. Among 273 patients, 43 (15.8%) developed LTA events. Seven independent predictors were identified: female sex, hemoglobin < 12 gm/dL, pre- and intra-procedural events (i.e., respiratory failure and pulseless arrest), IABP insertion, intervention duration > 60 min, and desaturation after pPCI. The LTA score showed an AuROC of 0.93 (95%CI 0.90, 0.97). The score was categorized into three risk categories: low (<2.5), moderate (2.5–4), and high risk (>4) for LTA events. The LTA score demonstrated high predictive performance and potential clinical utility for predicting LTA events after pPCI.

A systematic review and meta-analysis of impact of baseline thrombocytopenia on cardiovascular outcomes and mortality in patients undergoing percutaneous coronary intervention

BACKGROUND

Thrombocytopenia (TP) is associated with higher incidence of bleeding in the setting of percutaneous coronary intervention (PCI) leading to increased morbidity and mortality. Herein, we report a meta-analysis evaluating the effects of baseline thrombocytopenia (bTP) on cardiovascular outcomes in patients undergoing PCI.

METHODS

Literature search was performed using PubMed, Embase, Cochrane library and clinicaltrials.gov from inception till October 2019. Patients were divided into two groups: Patients with (a) no Thrombocytopenia (nTP) (b) bTP before PCI. Primary endpoints were in-hospital, and all-cause mortality rates at the longest follow-up. The main summary estimate was random effects risk ratio (RR) with 95% confidence intervals (CIs).

RESULTS

A total of 6,51,543 patients from 10 retrospective studies were included. There was increased in-hospital all-cause mortality (RR 2.58 [1.7-3.8], p < .001) and bleeding (RR 2.37 [1.41-3.98], p < .005), in the bTP group compared to the nTP group. There was no difference for in-hopsital major adverse cardiovascular outcomes (MACE) (RR 1.38 [0.94-2.0], p < .10), post-PCI MI (RR 1.17 [0.9-1.5], p = .19) and TVR (RR 1.65 [0.8-3.6], p = .21), respectively. Outcomes at longest follow-up showed increased incidence of all-cause mortality (RR 1.86 [1.2-2.9], p < .006) and bleeding (RR 1.72 [1.1-2.9], p = .04) in bTP group, while there was no significant difference for post-PCI MI (RR 1.07 [0.91-1.3], p = .42), MACE (RR 1.86 [0.69-1.8], p = .68) and TVR (RR 1.1 [0.9-1.2], p = .93) between both groups.

CONCLUSIONS

bTP in patients undergoing PCI is associated with increased mortality and predicts risk of bleeding.

Impact of Thrombocytopenia on In-Hospital Outcome in Patients Undergoing Percutaneous Coronary Intervention

Background

Thrombocytopenia was intuitively considered to be associated with higher risk of bleeding and multiple comorbidities after percutaneous coronary intervention (PCI). However, controversial results exist, and the real-world clinical impact of thrombocytopenia in patients undergoing PCI is largely unknown. The aim of this study was to evaluate the influence of baseline thrombocytopenia on the prognosis of patients undergoing PCI.

Methods

Using the West China Hospital Inpatient Sample database, patients who underwent PCI were identified from August 2012 to January 2019. Baseline thrombocytopenia was defined as a preprocedural platelet count of 100 × 10⁹/L or less obtained from a routine blood sample taken within 48 hours before coronary PCI. The clinical effect of the advanced thrombocytopenia group (≤85 × 10⁹/L), according to the median value of platelet count in the thrombocytopenia cohort, was further assessed. The primary outcome was a composite of in-hospital death, bleeding events, and post-PCI transfusion.

Results

Of 9531 patients enrolled in our study, 936 had baseline thrombocytopenia and 8595 patients did not have. There were no significant differences in the primary outcome between the two groups. However, advanced thrombocytopenia was independently associated with higher risk of primary outcome (OR 1.67, 95% CI 1.06 to 2.65, p = 0.029). Acute coronary syndrome (ACS) patients with thrombocytopenia were associated with higher odds of major bleeding (BARC ≥ 2) (OR 2.56, 95% CI 1.24 to 5.44, p = 0.011). Compared with the nonthrombocytopenia group, the thrombocytopenia group with ticagrelor use had higher odds of major bleeding (OR 9.7, 95% CI 1.57 to 60.4 versus OR 0.22, 95% CI 0.03 to 1.69, interaction p = 0.025).

Conclusions

It seems feasible for patients with thrombocytopenia to receive PCI, but close attention should be paid to advanced thrombocytopenia, the risk of postprocedure bleeding in ACS patients, and the use of more potent P2Y₁₂ inhibitor.

Dual anti-platelet therapy following percutaneous coronary intervention in a population of patients with thrombocytopenia at baseline: a meta-analysis

Background

In this meta-analysis, we aimed to systematically compare the post percutaneous coronary interventional (PCI) adverse bleeding events, stent thrombosis, stroke and other cardiovascular outcomes in a population of patients with and without thrombocytopenia at baseline who were followed up on dual antiplatelet therapy (DAPT).

Methods

Relevant English language articles which were published before June 2019 were retrieved from MEDLINE, http://www.ClinicalTrials.com, EMBASE, Cochrane central, and Google scholar briefly using specific terms such as percutaneous coronary intervention or dual antiplatelet therapy, and thrombocytopenia. All the participants were followed up on DAPT following discharge. Specific endpoints including bleeding events, stent thrombosis, stroke and other adverse cardiovascular events were assessed. The latest version of the RevMan software was used for the statistical assessment. Odd ratios (OR) with 95% confidence intervals (CI) based on a fixed or a random statistical model were used to represent the data graphically.

Results

A total number of 118,945 participants (from 8 studies) were included with 37,753 suffering from thrombocytopenia at baseline. Our results showed post procedural bleeding (OR: 1.89, 95% CI: 1.16–3.07; P = 0.01), access site bleeding (OR: 1.66, 95% CI: 1.15–2.39; P = 0.006), intra-cranial bleeding (OR: 1.78, 95% CI: 1.30–2.43; P = 0.0003), gastro-intestinal bleeding (OR: 1.44, 95% CI: 1.14–1.82; P = 0.002) and any major bleeding (OR: 1.67, 95% CI: 1.42–1.97; P = 0.00001) to be significantly higher in thrombocytopenic patients treated with DAPT after PCI. Total stroke (OR: 1.45, 95% CI: 1.18–1.78; P = 0.0004) specifically hemorrhagic stroke (OR: 1.67, 95% CI: 1.30–2.14; P = 0.0001) was also significantly higher in these patients with thrombocytopenia at baseline. All-cause mortality and major adverse cardiac events were also significantly higher. However, overall total stent thrombosis (OR: 1.18, 95% CI: 0.90–1.55; P = 0.24) including definite and probable stent thrombosis were not significantly different compared to the control group.

Conclusions

According to the results of this analysis, DAPT might have to be cautiously be used following PCI in a population of patients with thrombocytopenia at baseline due to the significantly higher bleeding rate including gastro-intestinal, intra-cranial bleeding and hemorrhagic stroke. Hence, special care might have to be taken when considering anti-platelet agents following PCI in these high risk patients. However, considering the present limitations of this analysis, this hypothesis will have to be confirmed in future trials.