Comparison between ticagrelor and clopidogrel in high bleeding risk patients with acute coronary syndrome

Background

Potent antiplatelet agents such as ticagrelor are associated with a lower risk of ischemic events than clopidogrel in patients with acute coronary syndrome (ACS). However, it is uncertain whether the benefits of more intensive anti-ischemic therapy outweigh the risks of major bleeding in individuals who have a high bleeding risk (HBR). This study aimed to assess treatment outcomes following dual antiplatelet therapy (DAPT) using either ticagrelor or clopidogrel in ACS patients with HBR.

Methods

All HBR patients enrolled in the SWEDEHEART registry who were discharged with DAPT using ticagrelor or clopidogrel following ACS between 2010 and 2017 were included in this study. Bleeding risk was assessed using the 4-item PRECISE-DAPT score, which consists of age, prior bleeding, haemoglobin concentration and creatinine clearance. HBR was defined as a PRECISE-DAPT score ≥25. Inverse-probability of treatment weighting was used to adjust for baseline differences between the treatment groups. The main analysis consisted of a doubly robust estimation of causal effect using Cox proportional hazards models. Data on major bleeding, recurrent myocardial infarction (MI), ischemic stroke and all-cause mortality was obtained from national registries, with 365 days of follow-up. Additional outcomes include major adverse cardiovascular events (MACE), a composite of MI, ischemic stroke and all-cause mortality, and net adverse clinical events (NACE), a composite of MACE and major bleeding.

Results

Of all ACS patients, 36% (n=25,042) had a PRECISE-DAPT score ≥25. Approximately half of the study participants were treated with ticagrelor (n=11,848). Ticagrelor reduced the risk of MI (hazard ratio [HR], 0.82 [95% CI 0.74–0.91]), ischemic stroke (HR, 0.73 [95% CI 0.60–0.88]) and MACE (HR, 0.90 [95% CI 0.84–0.97]), while also increasing the risk of major bleeding compared to clopidogrel (HR, 1.30 [95% CI 1.16–1.47]). We found no significant differences in all-cause mortality (HR 1.02 [95% CI 0.92–1.12]) and NACE (HR 0.98 [95% CI 0.92–1.05]).

Conclusions

Ticagrelor was associated with a lower risk of recurrent ischemic events, but a higher risk of major bleeding compared to clopidogrel. There were no significant differences in all-cause mortality and NACE between the treatment groups. These results suggest that more potent antiplatelet agents might not be superior to clopidogrel in ACS patients with HBR.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Stockholm county council

Immediate versus staged revascularisation in multivessel coronary disease: an updated meta-analysis

Background

Percutaneous coronary interventions (PCIs) are often aimed at the culprit vessel in acute coronary syndromes (ACSs) followed by revascularisation of other stenoses later in the index hospitalisation or shortly after discharge. PCI delay of non-culprit coronary vessels stenoses is supported by lower contrast fluid use and thrombocyte aggregation. Distinct coronary interventions increase the risk of both non- and coronary artery complications, e.g. acute abdominal and periphery artery bleeding, suggesting undertaking all PCIs at the same time.

Purpose

To assess the effect on mortality and re-myocardial infarction (MI) of immediate versus staged revascularisation in multivessel coronary disease, with the latter constrained to initial PCI of the culprit coronary vessel.

Methods

The syntax of “randomised controlled trial (RCT) & acute coronary syndrome & complete revascularisation” was undertaken in PubMed.

Clinical characteristics were gathered at the index hospitalisation. The intervention scenario was acute coronary syndrome or not.

Meta-analyses calculated relative risk (RR) reductions on outcomes of 1) mortality and 2) re-MI. Meta-regression assessed linear difference between interventional treatment benefits and baseline characteristics.

Results

A total of 148 studies was found. Of those, 8 was found eligible for further analyses and their baseline characteristics are shown in Table 1.

Comparison of immediate versus staged revascularisation on mortality was nonsignificant (RR, 1.19; 95% CI: 0.78–1.81, p=0.43) (Figure 1). The impact of Immediate vs staged revascularisation on re-MI was also nonsignificant (RR, 0.83; 95% CI: 0.44–1.55, p=0.56). Meta-regression found no associations between the outcomes and study characteristics (not shown).

Conclusion

The intervention of immediate compared to staged revascularisation assessed on outcomes of all-cause mortality and re-MI were nonsignificant.

Figure 1

Funding Acknowledgement

Type of funding source: None

Long term antithrombotic treatment in atrial fibrillation patients undergoing coronary surgery

Introduction

Current revascularisation guidelines from ESC recommend treatment with oral anticoagulants (OAC) alone in atrial fibrillation (AF) patients treated with coronary artery by-pass grafting (CABG), after one year of treatment with OAC and platelet inhibition (PI). Little is known about current treatment practice and there is a paucity of evidence to guide decision making.

Purpose

To assess treatment patterns and clinical outcome of OAC as sole antithrombotic treatment one year after CABG in patients with a history of AF, in comparison to PI only and OAC+PI.

Method

We included 2 112 patients (out of 32908 who underwent isolated CABG) from 2006 to 2014 with a history of atrial fibrillation, alive one year after surgery and a CHA2DS2-VASC-score ≥2. Based on data on individual dispensed prescriptions 1 to 1.5 years after surgery, patients were assigned to one of three treatment arms: PI alone (n=931), OAC alone (n=814) or combination of OAC+PI (n=367). Differences in MACE (death, myocardial infarction [MI] and stroke) between the three groups were assessed using a Cox regression model. Data are presented as hazard ratios (HR) with 95% confidence intervals [CI], adjusted for CHA2DS2-VASC-score (which include age, sex, hypertension [HT], congestive heart failure [CHF], stroke, vascular disease and diabetes) for MACE and the individual components of MACE; and CHA2DS2-VASC+history of bleeding regarding readmission for bleeding. Median follow-up was 3 years, range (0.5–3).

Results

Patients treated with PI only were younger (71, 72 and 73 years) and less often had HT (62%, 72 and 70%), and CHF (30, 40 and 40%) in the PI, PI+OAC and OAC groups respectively. Patients treated with PI only, more often had a history of MI (54%) compared to OAC (42%) but not to PI+OAC (53%). The cumulative incidence of MACE at three years was 18.9, 14.0 and 14.9% in the PI, PI+OAC and OAC groups, respectively. The corresponding numbers were for death 9.9, 9.0 and 11.2%, MI 4.6, 3.5 and 1.9%, stroke 6.0, 2.7 and 2.7% and readmission for bleeding 5.9, 11.3 and 7.0%, respectively. After adjustment, PI only was associated with significantly higher risk for MACE (HR 1.36, 95% CI: 1.06–1.75), MI (HR 2.82, 95% CI: 1.47–5.40), and stroke (HR 2.34, 95% CI: 1.36–4.02); while PI+OAC was associated with higher risk for MI (HR 2.43, 95% CI: 1.09–5.34) and bleeding complications (HR 1.58, 95% CI: 1.01–2.46), compared to OAC only.

Conclusions

In CABG patients with a history of AF and an indication for OAC, one year after surgery, treatment with OAC alone was associated with lower MACE rate than PI alone, driven by lower rates of MI and stroke. In addition, OAC only was associated with less bleeding complications than PI+OAC. These real-world data provide support to current ESC guidelines recommending OAC alone one year after CABG surgery.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): County council of Östergötland, Sweden

Uninterrupted oral anticoagulant therapy in patients undergoing unplanned percutaneous coronary intervention

Background

To investigate the optimal periprocedural antithrombotic strategy in patients on oral anticoagulants (OAC) who undergoing unplanned percutaneous coronary intervention (PCI).

Methods

Using data from the SWEDEHEART registry, we identified all patients on OAC who underwent an unplanned PCI, from 2005 to 2017. We compared uninterrupted OAC (U-OAC) vs interrupted OAC (I-OAC) therapy, defined as any discontinuation of OAC at least 24 hours prior to PCI. Outcomes were major adverse cardiac and cerebrovascular events (MACCE), including death, MI or stroke and net adverse cardiac and cerebrovascular events (NACCE), including MACCE or major bleeds, up to 120 days after the index procedure.

Results

We included 6485 patients, 3163 in U-OAC and 3322 in I-OAC group. The U-OAC strategy increased over time, by 13% per year. Almost 80% of patients in both groups had an acute coronary syndrome. We found no major differences in terms of medical history, clinical characteristics and the CRUSADE bleeding score on admission. The proportion of patients on warfarin was higher in the I-OAC group (85 vs 81%). Patients in the I-OAC were more likely to receive low-molecular weight heparin (29 vs 12%) and glycoprotein IIb/IIIa inhibitors (6 vs 3%) during the index hospitalisation. In the I-OAC group, dual antiplatelet therapy without OAC was more often prescribed (22 vs 8%) and OAC plus single antiplatelet therapy was less often prescribed (8 vs 22%) at discharge.

At 120 days, the cumulative rate of MACCE was 8.2 vs 8.2% and the rate of NACCE was 12.6 vs 12.9% in I-OAC vs U-OAC, respectively. We found no significant difference in the risk for MACCE and NACCE between the two groups (table). The risk for major or minor in-hospital bleeds was similar. I-OAC was associated with significantly longer time-delay to PCI and length of hospitalisation (table).

Conclusion

Uninterrupted OAC was safe and was associated with significantly shorter length of hospitalisation. Our data support U-OAC as the preferable strategy in patients on OAC undergoing PCI.

Funding Acknowledgement

Type of funding source: None

Spontaneous coronary artery dissection – contemporary management and outcome of a national cohort

Background

Spontaneous coronary artery dissection (SCAD) is proposed to cause 1–4% of all acute myocardial infarctions (AMI).

The aim of this study was to conduct a first description of Swedish SCAD patients regarding the prevalence of risk factors, treatment and prognosis.

Method

All patients with AMI registered in the Swedish Coronary Angiography and Angioplasty Register (SCAAR) December 2015 until December 2017 were included. The index angiographies of the SCAD patients were reevaluated by an independent angiographer at each center. Patients with non-SCAD AMI (n=31670) were used for comparison.

Results

SCAD was identified in 137 patients with AMI (100 women, 37 men). The SCAD population was younger than the non-SCAD population 53.9 (51.7–56.1) vs 68.5 (68.3–68.6) years, more often women (73.0 vs 30.7%) and presented with less risk factors: diabetes 2.9 vs 20.8%; hypertension 27.0 vs 57.6%; smoking 41.2 vs 58.1%; statin therapy 12.4 vs 36.9% and previous AMI 7.3 vs 19.6% (p<0.001 for all comparisons).

SCAD patients less frequently underwent percutaneous coronary intervention (PCI) 43.1 vs 70.8% (p<0.001) and received less statin treatment, 78.9 vs 91.5% (p<0.001).

There was no significant difference regarding treatment with aspirin or double antiplatelet therapy at discharge: 93 vs 89.7% (p=0.45) and 86.7 vs 84.2%, respectively (p=0,43).

There was no significant difference in one-year mortality 6.6 vs 8.2% (p=0.57).

Conclusions

With a current prevalence of 0.43% of all Swedish AMIs, data supports SCAD being an underdiagnosed condition with a prognosis resembling that of non-SCAD AMI. Furthermore, SCAD patients are younger and harbor less cardiovascular risk factors. While significant differences in management are present, current therapeutic strategies of the two groups are similar, indicating overtreatment of SCAD.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swedish Heart-Lung foundation, ALF funding

Utilization and outcomes of rotational atherectomy in Sweden

Aim

To evaluate utilization and outcomes of rotational atherectomy (RA) using data from the Swedish Coronary and Angioplasty Registry (SCAAR)

Methods

We included 1476 patients with 2218 lesions who underwent RA from 2005 to 2016. To study temporal changes, the study period was divided into three equal time-periods, period A, B and C.

Results

Although the number of RA procedures increased 3-fold from 2005 to 2016, the rate of RA (of all PCI procedures) remained low (0.5% vs 1.2% in 2005 vs 2016). RA patients consisted a high-risk group, with advanced age and clustering of comorbidities. Over time, included patients were older and had a higher risk profile. Trans-radial access, drug eluting stent (DES) use and use of intravascular imaging significantly increased from period A to C whereas positioning of a temporary pacemaker or intra-aortic balloon pump declined. Unfractionated heparin became the main anticoagulant (52 vs 87%) and use of glycoprotein IIb/IIIa inhibitors declined (31 vs 12%, in period A vs C). Following RA, 11% of lesions were treated without stent (15 vs 15 vs 8%, in period A, B and C) (Rota-only). In lesions treated with a stent, a bare metal stent (BMS) was implanted in 39% vs 12% vs 2% and a new generation DES (N-DES) in 5 vs 75 vs 97% (period A vs B vs C) of lesions.

The 3-year cumulative rate of restenosis was 6.7% (122 events), (11.1 vs 7.1 vs 4.1% in period A vs B vs C). As compared to DES, rota-only (adjusted HR 2.71; 95% CI 1.69- 4.36) and BMS (adjusted HR 3.63; 95% CI 2.27- 5.81) were associated with significantly higher risk for restenosis. First generation DES were associated with numerically higher but not significantly different risk for restenosis as compared to N-DES (adjusted HR 1.31; 95% CI 0.74- 2.31).

The 3 year cumulative rate of major adverse cardiac events (MACE), including death, myocardial infarction (MI) or any restenosis was 30.6% (34.2 vs 31.4 vs 28.2%, in period A vs B vs C) and the corresponding numbers for all-cause mortality were 18.1% (18.9 vs 18.4 vs 17.0%). After adjustment for baseline characteristics and angiographic findings, RA in period A was associated with higher risk for MACE as compared to period C (adjusted HR 1.40; 95% CI 1.09- 1.79), due to higher risk for MI and restenosis. The difference disappeared when procedural characteristics, including DES use, were added to the model.

The rate of major in-hospital complications was 7.0%, including in-hospital death 1.3%, periprocedural MI 2.8%, perforation 1.1%, cardiac tamponade 0.7%, stroke 0.2% and major bleedings 2.1%. We found no significant differences over time.

Conclusion

During the studied period, RA remained a rare procedure, utilised in a highly selected population. Over time a declining rate of restenosis and MI after RA was observed, a finding that appeared to be mainly driven by an increased use of DES. The rate of major in-hospital complication remained low.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific International

P1726A gender perspective on incidence, management, short- and long term outcome of cardiogenic shock complicating ST-elevation myocardial infarction - A report from the SWEDEHEART register

Background

Cardiogenic shock [CS] is a severe complication of ST-elevation myocardial infarction [STEMI]. An increased use of primary percutaneous coronary intervention [PPCI] has been associated with a decline in CS incidence, and a better prognosis. Female gender has been associated with a worse prognosis in STEMI, but whether there is a gender difference in incidence and outcome of CS complicating STEMI is not known.

Purpose

The objectives of this study were to compare the genders regarding incidence, management, and prognosis of CS complicating STEMI.

Methods

Patients with STEMI and CS were identified in SWEDEHEART 2005–2014. Cardiogenic shock was defined as any of; 1) systolic blood pressure [BP] <90 mm Hg ≥30 min, 2) signs of tissue hypoperfusion, 3) cardiac index <1,8 l/min/m2, 4) ionotropic drugs and/or need of intra-aortic balloon pump. Multiple logistic and cox regression analyses were done with reperfusion therapy, in-hospital and 1-year mortality as dependent variables.

Results

Among 56072 STEMI patients 3134 CS cases were identified. Women more often than men developed CS (6.3 vs 5.2%, p<0.001). The age-adjusted incidence of CS did not change in women, whereas in men the incidence increased by 2.7% yearly. Women had a less chance of receiving reperfusion therapy, OR 0.77 (95% CI 0.65–0.92), but had neither higher in-hospital mortality (OR 1.01, 95% CI 0.85–1.19), nor higher 1-year mortality (OR 0.97, 95% CI 0.70–1.33). Upon age stratification the gender difference in reperfusion was only evident among the oldest (>80 years).

Conclusion

Women had higher risk of CS than men when stricken by STEMI, but whereas CS incidence increased in men it was stable in women. Although women had less likelihood of receiving reperfusion therapy, adjusted in-hospital, and 1-year mortality was without any gender difference. The rate of reperfusion was especially low in elderly women, where there seems to be room for improvement.

Sex-related response to bivalirudin and unfractionated heparin in patients with acute myocardial infarction undergoing percutaneous coronary intervention: A subgroup analysis of the VALIDATE-SWEDEHEART trial

Aims:

Our aim was to study the impact of sex on anticoagulant treatment outcomes during percutaneous coronary intervention in acute myocardial infarction patients.

Methods:

This study was a prespecified analysis of the Bivalirudin versus Heparin in ST-Segment and Non ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated according to Recommended Therapies Registry Trial (VALIDATE-SWEDEHEART) trial, in which patients with myocardial infarction were randomised to bivalirudin or unfractionated heparin during percutaneous coronary intervention. The primary outcome was the composite of death, myocardial infarction or major bleeding at 180 days.

Results:

There was a lower risk of the primary outcome in women assigned to bivalirudin than to unfractionated heparin (13.6% vs 17.1%, hazard ratio 0.78, 95% confidence interval (0.60–1.00)) with no significant difference in men (11.8% vs 11.2%, hazard ratio 1.06 (0.89–1.26), p for interaction 0.05). The observed difference was primarily due to lower risk of major bleeding (Bleeding Academic Research Consortium definition 2, 3 or 5) associated with bivalirudin in women (8.9% vs 11.8%, hazard ratio 0.74 (0.54–1.01)) but not in men (8.5% vs 7.3%, hazard ratio 1.16 (0.94–1.43) in men, p for interaction 0.02). Conversely, no significant difference in the risk of Bleeding Academic Research Consortium 3 or 5 bleeding, associated with bivalirudin, was found in women 4.5% vs 5.4% (hazard ratio 0.84 (0.54–1.31)) or men 2.9% vs 2.1% (hazard ratio 1.36 (0.93–1.99)). Bleeding Academic Research Consortium 2 bleeding occurred significantly less often in women assigned to bivalirudin than to unfractionated heparin. The risk of death or myocardial infarction did not significantly differ between randomised treatments in men or women.

Conclusion:

In women, bivalirudin was associated with a lower risk of adverse outcomes, compared to unfractionated heparin, primarily due to a significant reduction in Bleeding Academic Research Consortium 2 bleeds.