Clinical utility of the academic research consortium new proposed criteria for high bleeding risk definition in patients with acute coronary syndromes

Background

The Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria have been proposed to stratify the bleeding risk of patients undergoing percutaneous coronary intervention (PCI). While most criteria were established, 4 criteria have been proposed on a de novo basis.

Purpose

We assessed the prevalence and prognosis of new ARC-HBR criteria in a contemporary, prospective, multicenter, quality-improvement registry of all-comers patients with acute coronary syndromes.

Methods

Between 2016 and 2020, consecutive subjects were enrolled; baseline characteristics and medications were prospectively collected, and patients were followed-up at 1 year. All clinical events (including bleeding) were adjudicated by an independent committee. All 17 ARC-HBR criteria were individually evaluated by reviewing patients' charts.

Results

Of the 2804 patients enrolled, 782 (28.0%) met the ARC-HBR definition and 47 (6%) of them experienced a major BARC 3 or 5) bleeding at 1-year. HBR patients had a significantly higher risk of BARC 3–5 bleedings (HR for: 3.07; 95% CI: 2.02–4.67; p<0.0001; Fig. 1A), BARC 2–5 (HR: 1.845; 95% CI: 1.4–2.42; p<0.0001). Fig. 1B indicates the proportion of patients meeting each criterion. Age, (moderate or severe) chronic kidney disease, (moderate or severe) anemia and oral anticoagulant therapy included 88% of HBR patients.

The 4 new ARC-HBR criteria, all together, were present in only 1.7% of our population: 1.0% was planned for major surgery while on dual antiplatelet therapy, 0.5% had a recent intracranial hemorrhage/ictus or brain arteriovenous malformations, 0.1% had hepatic cirrhosis with portal hypertension and 0.1% had a recent surgery or trauma. In a multivariable Cox regression analysis including individual ARC-HBR criteria, only CKD (major and minor criteria), anemia (major and minor criteria) and cancer were the independent predictors of BARC 3–5 events with a concordance-index for this model of 0.698 (p<0.001). In a second model including only CKD (major criterion), anemia (major criterion), age and oral anticoagulation therapy, all these criteria were independent predictors of BARC 3–5 events with a concordance index of 0.674 (pmodel<0.001 for the model) (Fig. 2).

Conclusion

Almost one third of contemporary ACS patients was at HBR according to the ARC-HBR definition and these patients presented a significantly higher risk of bleedings at 1-year. The most common 4 criteria (age, CKD, anemia, and oral anticoagulant therapy) allowed the identification of 88% of HBR patients. The newly proposed HBR criteria were extremely rare and therefore challenging to validate and of uncertain clinical utility. These data may inform and simplify clinical decision making and provide priority for future directions of HBR definitions.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Prognosis and prescriptions of glifozines in candidates patients in a prospective, multicenter, quality-improvement study of patients with acute coronary syndrome

Background

Sodium-glucose transporter 2 inhibitors (SGLT2-i) have demonstrated substantial improvement in clinical outcomes for patients with heart failure (HF) and chronic kidney disease (CKD) with or without diabetes mellitus (DM). Prescription patterns and outcome of SGLT2-i candidates in patients hospitalized for an acute coronary syndrome (ACS) are less well established.

Purpose

We aimed to assess the proportion of candidates to SGLT2-i and to characterize their clinical outcome in a contemporary, prospective, multicenter, quality-improvement study of all-comers patients with ACS. We also aimed to ascertain prescriptions of SGLT2-i at discharge.

Methods

Between 2018 and 2020, subjects were enrolled in the study; baseline characteristics and medications were prospectively collected, and patients were followed-up at 1 year. Subjects were considered candidates to SGLT2-i if any of the following were: (i) known (medically treated) or new (HbA1c >6.5%) diagnosis of type 2 DM; (ii) left ventricular systolic dysfunction (LVSD; new or known left ventricular ejection fraction <40%) or clinical HF; (iii) CKD (estimated glomerular filtration rate 25–74 mL/min/m2, according to DAPA-CKD trial eligibility).

Results

Of the 2804 consecutive ACS patients enrolled, 798 (28.5%) had new or known DM and only 10 were already on SGLT2-I at baseline. Additionally, 1,098 (39.2%) patients qualified for SGLT2-i prescription as having known or new LVSD or HF, and 803 (28.6%) as having CKD. (Fig. 1A) Overall, these 1,767 (63.1%) SGLT2-i candidates had substantially higher hazard of death as compared to no candidate (Hazard Ratio [HR] at 1-year: 6.82; 95% Confidence Interval: 4.32–10.8; p<0.001; Fig. 1B) and each indication to SGLT2-i independently predicted death at 1 year (HR: 2.30/2.11/3.06; 95% CI: 1.78–2.97/1.62–2.74/2.35–3.97; all p<0.0001; for DM, HF, CKD, respectively; Fig. 2). At discharge, only 18 (1.0% of the candidates) were prescribed with SGLT2-i and, of those with DM, having a diabetological consultation before discharged modestly but significantly increased the likelihood of being discharged with SGLT2-i (4.3% vs. 6.6%; p=0.0015).

Conclusion

Most (two out of three) contemporary ACS patients are candidates to SGLT2-i therapy, and they have a significant and substantial higher risk of mortality at 1-year as compared to no candidates. Current prescription rates are still extremely low (1%) and highlight opportunity for quality improvement and multidisciplinary decision-making.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Myocardial injury in patients hospitalized for SARS-CoV19: a maker or a marker of prognosis?

Background

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, literature data are progressively accumulating, attesting to the possible prognostic role of cardiac troponins in patients who need hospitalization because of COVID-19 infection.

Purpose

To assess whether myocardial injury (measured by high sensitivity troponins) is an independent cause of disease severity and prognosis.

Methods

We performed a patient-level metanalysis (PROSPERO ID: CRD42020213209) in unselected patients hospitalized because of COVID-19 infection in whom the severity of respiratory failure was also evaluated at admission. To allow for comparison, troponin values were normalized to their threshold levels to obtain a normalized troponin (nTn) value which was used as a continuous variable in all analysis.

Results

A total of 722 patients were included in the analysis. Of note, patients who had elevated troponins at hospital admission had a significantly lower oxygenation status than those with normal nTn (PaO2/FiO2 232±215 vs. 276±124 mmHg/%; p<0.001). On the contrary, those with cardiovascular comorbidities had similar PaO2/FiO2 but higher nTn than those without (5.6817 vs. 2.1110 ng/mL; p=0.002).

After a median follow-up of 14 days, 180 deaths were observed. At multivariable regression analysis, age, male sex, moderate-severe renal dysfunction (eGFR <30 mL/min/m2) and lower PaO2/FiO2, were independent predictor of death (igure 1). The restricted cubic spline curves in Figure 2A and 2B show the hazard ratios (HRs) and 95% confidence interval for death according to nTn and PaO2/FiO2 levels as continuous variables. A linear increase in the HR is observed with lower PaO2/FiO2 values below the normal value of 300. On the contrary, the nTn spline curve is near-flat with large confidence interval for values above the normality thresholds.

Conclusion

In patients hospitalized for COVID-19, mortality is mainly driven by gender, age and respiratory failure while myocardial damage is not an independent predictor of worse survival when respiratory function is accounted for.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

P1856Percutaneous mitral edge-to-edge valvuloplasty in end-stage heart failure as a bridge to heart transplant: a case series from a single tertiary referral center

Background

Improved outcomes after percutaneous edge-to-edge mitral valvuloplasthy with MitraClip implantation were recently observed in patients with heart failure (HF) and functional severe mitral regurgitation (MR). Nonetheless, its efficacy in end-stage heart failure (HF) are lacking.

Purpose

Our aim was to investigate feasibility, preliminary efficacy on hemodynamics and follow-up of MitraClip implantation in a cohort of patients with very advanced HF.

Methods

Patients were retrospectively included in the present analysis if already in HT list, unsuitable for HT despite optimal medical and device therapy, or if implantation was a “bridge-to-candidacy”.

Results

Baseline and procedural characteristics are listed in Table 1; MR etiology was predominantly functional (n=7). No major complications were observed in the peri-operative period. At 6-month follow-up, invasive hemodynamics was available for 8 patients. A significant increase in cardiac index was observed (Least Square Mean Difference, LSMD = +0.47 L/min/m2; p=0.03; Figure 1), in conjunction with a numerical reduction in pulmonary vascular resistance (LSMD = −1.02 WU; p=0.3), a trend towards lower mean pulmonary arterial pressure (LSMD = −6.5 mmHg; p=0.053) and lower ejection fraction (LSMD = −6.5%; p=0.053). At a median follow-up of 772 days (IQR 156–1,578), all three patients unsuitable for HT at baseline could be eligible to HT list and one of them received LVAD. Moreover, two patients were transplanted, four experienced unplanned rehospitalization for HF, and one died of non-cardiac cause.

Table 1. Baseline clinical evaluation (n=10) Age (y) 53.67±8.43 HF Etiology – post ischemic 4 (40) Male sex 6 (60) HF Etiology – no CAD 4 (40) Body Surface Area (m2) 1.76±0.22 HF Etiology – other 2 (20) Chronic Resynchronization Therapy 5 (50) Euroscore II 6.00±2.74 Baseline MR grade (+) 4 (40) STS mortality 1.71±2.65 Residual MR grade (+) 1.71±0.49 Clips implanted (number) 1.78±0.67 Data are expressed as mean ± SD or count (valid %). MR scored on a scale from 0+ to 4+. STS, Society of Thoracic Surgeons.

Figure 1

Conclusions

Percutaneous edge-to-edge mitral valvuloplasty with MitraClip appears safe and effective in end-stage patients, impacts on clinical decision-making and therefore might be considered as a “bridge” towards a more definite strategy.

Acknowledgement/Funding

None