Complete Revascularization Versus Culprit-Lesion-Only PCI in STEMI Patients With Diabetes and Multivessel Coronary Artery Disease: Results From the COMPLETE Trial

BACKGROUND

In the COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI), a strategy of complete revascularization reduced the risk of major cardiovascular events compared with culprit-lesion-only percutaneous coronary intervention in patients presenting with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease. Patients with diabetes have a worse prognosis following STEMI. We evaluated the consistency of the effects of complete revascularization in patients with and without diabetes.

METHODS

The COMPLETE trial randomized a strategy of complete revascularization, consisting of angiography-guided percutaneous coronary intervention of all suitable nonculprit lesions, versus a strategy of culprit-lesion-only percutaneous coronary intervention (guideline-directed medical therapy alone). In prespecified analyses, treatment effects were determined in patients with and without diabetes on the first coprimary outcome of cardiovascular death or new myocardial infarction and the second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Interaction P values were calculated to evaluate whether there was a differential treatment effect in patients with and without diabetes.

RESULTS

Of the 4041 patients enrolled in the COMPLETE trial, 787 patients (19.5%) had diabetes. The median HbA1c (glycated hemoglobin) was 7.7% in the diabetes group and 5.7% in the nondiabetes group. Complete revascularization consistently reduced the first coprimary outcome in patients with diabetes (hazard ratio, 0.87 [95% CI, 0.59-1.29]) and without diabetes (hazard ratio, 0.70 [95% CI, 0.55-0.90]), with no evidence of a differential treatment effect (interaction P=0.36). Similarly, for the second coprimary outcome, no differential treatment effect (interaction P=0.27) of complete revascularization was found in patients with diabetes (hazard ratio, 0.61 [95% CI, 0.43-0.87]) and without diabetes (hazard ratio, 0.48 [95% CI, 0.39-0.60]).

CONCLUSIONS

Among patients presenting with STEMI and multivessel disease, the benefit of complete revascularization over a culprit-lesion-only percutaneous coronary intervention strategy was consistent regardless of the presence or absence of diabetes.

Association Between Perioperative Atrial Fibrillation and Long-term Risks of Stroke and Death in Noncardiac Surgery: Systematic Review and Meta-analysis

BACKGROUND

Atrial fibrillation (AF) is frequently reported as a complication of noncardiac surgery. It is unknown whether new-onset perioperative AF is associated with an increased risk of stroke and death beyond the perioperative period. We performed a systematic review and meta-analysis to assess the long-term risks of stroke and mortality associated with new-onset perioperative AF after noncardiac surgery.

METHODS

MEDLINE and EMBASE were searched from inception to March 2020 for studies reporting on the association between perioperative AF and the risk of stroke and death occurring beyond 30 days after noncardiac surgery. Reference screening, study selection, data extraction, and quality assessment were performed in duplicate. Data were pooled using inverse variance-weighted random-effects models and presented as risk ratios (RRs).

RESULTS

From 7344 citations, we included 31 studies (3,529,493 patients). The weighted mean incidence of perioperative AF was 0.7%. During a mean follow-up of 28.1 ± 9.4 months, perioperative AF was associated with an increased risk of stroke (1.5 vs 0.9 strokes per 100 patient-years; RR: 2.9, 95% confidence interval [CI]: 2.1-3.9, I2 = 78%). Perioperative AF was also associated with a significantly higher risk of all-cause mortality (21.0 vs 7.6 deaths per 100 patient-years; RR: 1.8, 95% CI: 1.5-2.2, I2 = 94%). The pooled adjusted hazard ratios for stroke and all-cause mortality were 1.9 (95% CI: 1.6-2.2, I2 = 31%) and 1.5 (95% CI: 1.3-1.7, I2 = 20%), respectively.

CONCLUSIONS

Patients who had perioperative AF after noncardiac surgery had a higher long-term risk of stroke and mortality compared with patients who did not. Whether this risk is modifiable with oral anticoagulation therapy should be investigated.

Association of a history of falls or syncope with intracranial bleeding in patients with atrial fibrillation

Background

In patients with atrial fibrillation (AF), anticoagulation effectively reduces the risk of ischemic stroke. However, up to 50% of patients are not receiving this treatment. A history of falls or syncope and an associated risk of intracranial hemorrhage are commonly reported reasons for undertreatment, though these have not been well studied.

Purpose

To investigate the association of a history of falls or syncope with the risk of intracranial hemorrhage in patients with AF.

Methods

Patients with a history of AF from the RE-LY, AVERROES and ACTIVE A and W trials were combined into a large cohort. “Critical injury” was defined as any injury that resulted in death, was deemed to be life-threatening or resulted in permanent disability. A “serious injury” was defined as an injury that required hospitalization. “Other injuries” were defined as those that did not meet criteria for critical or serious injury. We used logistic regression and propensity-matched Cox models to assess the association between falls or syncope and adverse outcomes.

Results

Among 37,973 patients, 11.9% (n=4503) had a history of falls, 17.5% (n=6655) had a history of syncope and 25.1% (n=9518) had a history of either falls or syncope. The mean age of the cohort was 71±9.3 years and 58% were male. The median CHADS2 score was 2. A history of falls or syncope was not associated with the risk of incident intracranial hemorrhage (HR 1.11, 95% CI 0.88–1.4). In propensity-matched multivariable models, a history of falls or syncope was associated with an increased risk of death (HR 1.14, 95% CI 1.07–1.22), stroke (HR 1.17, 95% CI 1.05–1.3), myocardial infarction (HR 1.28, 95% CI 1.09–1.52) and major bleeding (HR 1.27, 95% CI 1.16–1.4). Moreover, a history of falls or syncope was associated with increased risk of critical injury (OR 1.97, 95% CI 1.52–2.54), serious injury (OR 2.06, 95% CI 1.75–2.43) and “other injury” (OR 1.58, 95% CI 1.46–1.72).

Conclusions

A history of falls or syncope is common in patients with atrial fibrillation; however, neither history was associated with increased risk of intracranial hemorrhage. These patients were at an increased risk of death, stroke, myocardial infarction and major bleeding, suggesting that they should receive anticoagulation for stroke prevention.

Funding Acknowledgement

Type of funding source: None

What is the Impact of Frailty on Prescription of Anticoagulation in Elderly Patients with Atrial Fibrillation? A Systematic Review and Meta-Analysis

Background

Atrial fibrillation (AF) and frailty are both associated with advanced age. Oral anticoagulants (OAC) effectively prevent strokes in AF patients but are underutilized in the elderly, possibly due to misperception of frailty.

Objective

We performed a systematic review to determine the prevalence of frailty in patients with AF, and whether frailty was associated with reduced prescription of OAC.

Methods

We systematically searched Cochrane, MEDLINE, EMBASE, and PubMed databases. Search terms combined relevant words and MeSH headings: 1) atrial fibrillation, 2) frail elderly, and 3) geriatric assessments. Studies that measured frailty using a validated instrument, and involved OAC for AF in frail and non-frail patients were eligible for inclusion. Pooled odds ratios were calculated using random-effects model.

Results

Of 166 reviewed titles, only 3 studies (1204 patients) met the inclusion criteria. Two used the Reported Edmonton Frail Scale (total 509 patients), and one used the Canadian Study of Health and Aging Clinical Frailty Scale (682 patients). All 3 studies involved hospitalized patients with an average age of 85 ± 6 and 45% were male. The weighted mean prevalence of frailty in patients with atrial fibrillation was 39% (95%CI 36-42). The weighted mean rate of OAC use was 57±11%. Frailty was associated with non-prescription of OAC compared to non-frail (OR 0.49, 95% CI 0.32-0.74, I2 =45%).

Conclusion

The prevalence of frailty in hospitalized elderly patients with AF is high, and the use of OAC is low in these patients. Frail elderly are significantly less likely to receive OAC.

Which Factors Influence Resident Physicians to Prescribe NOACs to Patients with Non-Valvular Atrial Fibrillation?

The Canadian Cardiovascular Society and the European Society of Cardiology recommend the use of non-vitamin K antagonists (NOAC) in preference to warfarin for stroke prevention in most patients with non-valvular atrial fibrillation (AF). The aim of this study was to identify factors that predict selection of a NOAC by resident physicians when faced with patients with non-valvular AF. A web-based survey was distributed to residents across Canada to learn the attitudes and behaviours regarding stroke, bleeding risk and choices of therapy in different clinical scenarios involving the same patient and one additional co-morbidity. There were a total of 1014 respondents. In an uncomplicated patient with a new diagnosis of AF, self-reported comfort level was the strongest positive predictor for selecting a NOAC (odds ratio (OR) 2.51; 95% confident interval (CI) 1.79-3.54). Residents' desire for the availability of a reversal agent was a negative predictor (OR 0.55; 95%CI 0.39-0.77). In a patient with a prior gastrointestinal bleed, each additional year of training was associated with a choosing a NOAC (OR 1.3; 95%CI 1.1-1.5). In the same patient, the desire for the availability of a reversal agent was a negative predictor of selecting a NOAC (OR 0.42; 95%CI 0.32-0.56). The most consistent predictor for prescribing a NOAC in all clinical scenarios was self-reported comfort level. Fear of adverse events, cost of agents and dosing convenience were not significant predictors. This study found that resident physicians' adherence to guideline-preferred management of AF with regards to stroke prevention is strongly associated with self-reported comfort level, training year and the desire for the presence of a reversal agent.

The anticoagulation choices of internal medicine residents for stroke prevention in non-valvular atrial fibrillation

PURPOSE OF THE STUDY

To explore the oral anticoagulation (OAC) prescribing choices of Canadian internal medicine residents, at different training levels, in comparison with the Canadian Cardiovascular Society (CCS) guidelines for non-valvular atrial fibrillation (NVAF).

STUDY DESIGN

Cross-sectional, web-based survey, involving clinical scenarios designed to favour the use of non-vitamin K antagonists (NOACs) as per the 2014 CCS NVAF guidelines. Additional questions were also designed to determine resident attitudes towards OAC prescribing.

RESULTS

A total of 518 internal medicine responses were analysed, with 196 postgraduate year (PGY)-1s, 169 PGY-2s and 153 PGY-3s. The majority of residents (81%) reported feeling comfortable choosing OAC, with 95% having started OAC in the past 3 months. In the initial clinical scenario involving an uncomplicated patient with a CHADS2 score of 3, warfarin was favoured over any of the NOACs by PGY-1s (81.6% vs 73.9%), but NOACs were favoured by PGY-3s (88.3% vs 83.7%). This was the only scenario where OAC choices varied by PGY year, as each of the subsequent clinical scenarios residents generally favoured warfarin over NOACs irrespective of level of training. The majority of residents stated that they would no longer prescribe warfarin once NOAC reversal agents are available, and residents felt risk of adverse events was the most important factor when choosing OAC.

CONCLUSIONS

Canadian internal medicine residents favoured warfarin over NOACs for patients with NVAF, which is in discordance with the evidence-based CCS guidelines. This finding persisted throughout the 3 years of core internal medicine training.

Resident Physicians Choices of Anticoagulation for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation

Atrial fibrillation (AF) is a common cardiac arrhythmia and is associated with an increased risk of ischemic stroke. The aim of this study was to identify practice patterns of Canadian resident physicians pertaining to stroke prevention in nonvalvular AF according to the Canadian Cardiovascular Society guidelines. A Web-based survey consisting of 16 multiple-choice questions was distributed to 11 academic centres. Questions involved identification of risks of stroke, bleeding, and selection of appropriate therapy in clinical scenarios that involve a patient with AF with a Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack (CHADS2) score of 3 and no absolute contraindications to anticoagulation. There were 1014 total respondents, of whom 570 were internal, 247 family, 137 emergency medicine, and 60 adult cardiology residents. For a patient with a new diagnosis of AF, warfarin was chosen by 80.3%, novel oral anticoagulants (NOACs) by 60.3%, and acetylsalicylic acid (ASA) by 7.2% of residents. To a patient with a history of gastrointestinal bleed during ASA treatment, warfarin was recommended by 75.1%, NOACs by 36.1%, ASA by 12.1%, and 4% were unsure. For a patient with a history of an intracranial bleed, warfarin was recommended by 38.8%, NOACs by 23%, ASA by 24.8%, and 18.2% were unsure. For a patient taking warfarin who had a labile international normalized ratio, 89% would switch to a NOAC and 29.5% would continue warfarin. This study revealed that, across a wide sampling of disciplines and centres, resident physician choices of anticoagulation in nonvalvular AF differ significantly from contemporary Canadian Cardiovascular Society guidelines.

Are the cardiovascular side effects of bevacizumab caused by autonomic nervous system toxicity?

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Background: Bevacizumab, a monoclonal antibody that inhibits the activity of vascular endothelial growth factor, has demonstrated activity against several malignancies. Reported adverse effects include hypertension, endothelial dysfunction, and heart failure. Animal models have suggested ANS toxicity as the mechanism. This pilot study investigates the effects of bevacizumab on short and long-term ANS function using a pre-post intervention design protocol. We report on the acute effects herein. Methods: Patients were recruited among those starting bevacizumab for colon cancer. A 10-minute ECG was recorded prior to, during, and following a first dose and analysed for heart rate variability (HRV), a marker of ANS dysfunction. The HRV values were compared using paired t-tests and repeated measures ANOVA. Plasma hormones were drawn before and after infusion and compared using paired t-tests. Results: Nine patients without a cardiac history were tested. Mean age was 63 years and 5 were male. All were in sinus rhythm with normal systolic function by echo. The Table reports changes in HRV indices and plasma hormones. Conclusions: Acute administration of bevacizumab produced a statistically significant decrease in plasma aldosterone and was associated with a trend towards decreases in plasma norepinephrine and the low/high frequency domain ratio of HRV. These changes may be signs of an early ANS imbalance. Both a larger patient series and longer follow-up are planned to characterize the effects of bevacizumab on the ANS. [Table: see text]