Relationship of PRECISE-DAPT and DAPT scores with mortality in patients admitted with acute coronary syndrome who undergo coronary stent implantation

Abstract Introduction International guidelines recommend using risk score tools that allow us to assess the risk of bleeding and ischemia when deciding on DAPT. In our research, we aimed to examine the mortality relationship of new risk scores, DAPT and PRECISE-DAPT scores. Method Between 2013–2014, 948 patients admitted to our clinic with ACS were included in our study. We excluded 688 patient (no contact number,CABG, medical treatment, use of oral anticoagulation, active malignant cancer). 260 patients admitted with acute coronary syndrome (58%, 8 STEMI, 35%, 4 non-STEMI, 5%, 4 Unstable angina pectoris) who undergo coronary stent implantation were included in the study. We aimed to focus on the patients who undergo percutaneous coronary intervention and their risk of mortality. The patients' records were retrospectively analyzed through the hospital information system and archive records. Laboratory results, echocardiography and CAG reports of the patients, disease histories were obtained from the information recorded through the system. With these data, PRECISE-DAPT and DAPT scores of patients were calculated. Results The number of patients with a PRECISE-DAPT Score ≥25 was 62 (23.8%). The number of patients with DAPT Score ≥2 was 193 (74.2%). Mortality occurred in 49 (18.8%) patients. Patients with PRECISE-DAPT ≥25 and those with PRECISE-DAPT <25 were compared in terms of mortality and mortality was significantly higher in the high-scoring group [P <0.001 OR 6.94 C (3.53–13.62)]. The patients were divided into 4 groups (PRECISE-DAPT 25 and DAPT ≥2, PRECISE-DAPT ≥25 and DAPT ≥2, PRECISE-DAPT 25 and DAPT 2, PRECISE-DAPT ≥25 and DAPT 2) according to PRECISE-DAPT and DAPT score. Mortality was significantly higher regardless of DAPT score in patients with high PRECISE-DAPT scores (p<0.001). We evaluated the relationship between PRECISE-DAPT score and major bleeding and all bleeding. Compared to the group there was no significant difference in all bleeding events (P=0.56) and major bleeding events (P=0.23). The relationship between bleeding events and mortality was evaluated. There was no significant difference in mortality (p=0.689) with all bleeding events; but mortality was significantly increased in patients with major bleeding [P=0.025 OR 6.16 (1,33–28,49)]. Conclusion In our study, we observed that the patient group with a high PRECISE-DAPT score had a high mortality rate regardless of the DAPT score. The PRECISE-DAPT score is a useful tool in determining the group with high long-term mortality in patients who present with acute coronary syndrome and undergo percutaneous coronary intervention. The clinician should use the PRECISE-DAPT score when deciding on the duration of dual antiplatelet therapy in this patient group and these patients with high scores need to be monitored more closely. The data we have obtained from our study is retrospective and these results need to be supported by prospective and large studies. FUNDunding Acknowledgement Type of funding sources: None.

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Early aspirin discontinuation following acute coronary syndrome or percutaneous coronary intervention: a systematic review and meta-analysis of randomized controlled trials

European Heart Journal ◽

10.1093/ehjci/ehaa946.1428 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

P Guedeney ◽

J Mesnier ◽

S Sorrentino ◽

F Abcha ◽

M Zeitouni ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Randomized Controlled Trials ◽

Major Bleeding ◽

Coronary Intervention ◽

Controlled Trials ◽

Coronary Syndrome ◽

Randomized Controlled ◽

Percutaneous Coronary ◽

Significant Difference

Abstract Background The respective ischemic and bleeding risks of early aspirin discontinuation following an acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) remains uncertain. Objectives To evaluate the safety and efficacy of early aspirin discontinuation in ACS or PCI patients treated with P2Y12 inhibitors with or without anticoagulants. Methods We performed a review of randomized controlled trials (RCTs) comparing a P2Y12 inhibitor-based single antiplatelet strategy following early aspirin discontinuation to a strategy of sustained dual antiplatelet therapy (DAPT) in ACS or PCI patients requiring or not anticoagulation for another indication. The primary safety endpoint was major bleeding while non-major bleeding and all bleeding were secondary safety endpoints. The primary efficacy endpoint was all-cause mortality while secondary efficacy endpoints included major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), definite stent thrombosis (ST) or any stroke. We estimated risk ratios (RR) and 95% confidence intervals (CI) using random effect models. The study is registered in PROSPERO (CRD42019139576). Results We included 9 RCTs comprising 40,621 patients.Compared to prolonged DAPT, major bleeding (2.2% vs. 2.8%; RR 0.68; 95% CI: 0.54 to 0.87; p=0.002; I2: 63%), non-major bleeding (5.0% vs. 6.1%; RR: 0.66; 95% CI: 0.47 to 0.94; p=0.02; I2:87%) and all bleeding (7.4% vs. 9.9%; RR: 0.65; 95% CI: 0.53 to 0.79; p<0.0001; I2: 88%) were significantly reduced with early aspirin discontinuation (Figure 1), without significant difference for all-cause death (p=0.60), MACCE (p=0.60), MI (p=0.77), definite ST (p=0.63), and any stroke (p=0.59). Results were consistent in patients with or without anticoagulation, without significant interaction for any outcomes but MI (p=0.04). Conclusions In patients on DAPT after an ACS or a PCI, early aspirin discontinuation prevents bleeding events with no effect on the ischemic risk or mortality. Figure 1. Central illustration Funding Acknowledgement Type of funding source: None

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Ticagrelor monotherapy vs clopidogrel monotherapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention

European Heart Journal ◽

10.1093/ehjci/ehaa946.1722 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

W Feng ◽

P.W Chen ◽

M.Y Ho ◽

C.H Su ◽

S.W Huang ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Primary Endpoint ◽

Major Bleeding ◽

Lower Risk ◽

Coronary Intervention ◽

Coronary Syndrome ◽

Percutaneous Coronary ◽

Significant Difference ◽

All Cause Mortality

Abstract Background P2Y12 inhibitor monotherapy with either clopidogrel or ticagrelor becomes an alternative antiplatelet strategy in patients (pts) undergoing percutaneous coronary intervention (PCI). The purpose of this study was to compare the efficacy and safety of clopidogrel vs. ticagrelor monotherapy in pts with acute coronary syndrome (ACS) undergoing PCI who cannot tolerate aspirin. Methods and results From January 1, 2014 to December 31, 2018, a total of 610 ACS pts (mean age 70.4±13.1 years, 72.1% men, 28.5% STEMI) that aspirin was stopped prematurely for various reasons and received either clopidogrel (n=369) or ticagrelor (n=241) monotherapy were included from 8 major hospitals in Taiwan. The duration (median and the 25th and 75th percentile) of aspirin treatment was 9 (1.39–37.00) days in the clopidogrel group and 10 (1.00–55.00) days in the ticagrelor group (p=0.514). Gastrointestinal bleeding (36.9%) was the most common reason to stop aspirin in both groups. The primary endpoint is the composite of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months after discharge. The safety endpoint was the major bleeding defined as BARC 3 or 5 bleedings. The covariates were balanced between groups after using inverse probability of treatment weighting. Overall, 84 patients developed events of primary endpoint, with 57 (15.4%) in the clopidogrel group and 27 (11.2%) in the ticagrelor group. After multivariate adjustment in the Cox proportional-hazards models, ticagrelor was associated with a lower risk of primary endpoint compared with clopidogrel (adjusted hazard ratio [aHR] 0.67, 95% CI 0.49–0.93). Among the primary endpoint, ticagrelor significantly reduced the risk of recurrent ACS or unplanned revascularization (aHR 0.46, 95% CI 0.28–0.75). There was no significant difference of all-cause mortality between the 2 groups (aHR 0.92, 95% CI 0.52–1.61). The risk of BARC 3 or 5 bleeding was also similar (aHR 0.71, 95% CI 0.35–1.45). Conclusions Among ACS patients undergoing PCI who cannot tolerate aspirin, ticagrelor monotherapy was associated with a significantly lower risk of a composite of cardiovascular events compared to clopidogrel monotherapy. The major bleeding risk was similar between groups. Funding Acknowledgement Type of funding source: None

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Early Aspirin Discontinuation Following Acute Coronary Syndrome or Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Journal of Clinical Medicine ◽

10.3390/jcm9030680 ◽

2020 ◽

Vol 9 (3) ◽

pp. 680 ◽

Cited By ~ 5

Author(s):

Paul Guedeney ◽

Jules Mesnier ◽

Sabato Sorrentino ◽

Farouk Abcha ◽

Michel Zeitouni ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Randomized Controlled Trials ◽

Major Bleeding ◽

Coronary Intervention ◽

Controlled Trials ◽

Coronary Syndrome ◽

Randomized Controlled ◽

Percutaneous Coronary ◽

Significant Difference

The respective ischemic and bleeding risks of early aspirin discontinuation following an acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) remain uncertain. We performed a prospero-registered review of randomized controlled trials (RCTs) comparing a P2Y12 inhibitor-based single antiplatelet strategy following early aspirin discontinuation to a strategy of sustained dual antiplatelet therapy (DAPT) in ACS or PCI patients requiring, or not, anticoagulation for another indication (CRD42019139576). We estimated risk ratios (RR) and 95% confidence intervals (CI) using random effect models. We included nine RCTs comprising 40,621 patients. Compared to prolonged DAPT, major bleeding (2.2% vs. 2.8%; RR 0.68; 95% CI: 0.54 to 0.87; p = 0.002; I2: 63%), non-major bleeding (5.0 % vs. 6.1 %; RR: 0.66; 95% CI: 0.47 to 0.94; p = 0.02; I2: 87%) and all bleeding (7.4% vs. 9.9%; RR: 0.65; 95% CI: 0.53 to 0.79; p < 0.0001; I2: 88%) were significantly reduced with early aspirin discontinuation without significant difference for all-cause death (p = 0.60), major adverse cardiac and cerebrovascular events (MACE) (p = 0.60), myocardial infarction (MI) (p = 0.77), definite stent thrombosis (ST) (p = 0.63), and any stroke (p = 0.59). In patients on DAPT after an ACS or a PCI, early aspirin discontinuation prevents bleeding events with no significant adverse effect on the ischemic risk or mortality.

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Safety and efficacy of bivalirudin in diabetic acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI)

European Heart Journal ◽

10.1093/eurheartj/ehab724.1437 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

A Golam Mostofa ◽

T Parvin ◽

R Masum Mandal ◽

S Ali Ahsan ◽

R Afrin

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Major Bleeding ◽

Guide Wire ◽

Coronary Intervention ◽

Diabetic Patients ◽

Safety And Efficacy ◽

Coronary Syndrome ◽

Percutaneous Coronary ◽

Hemorrhagic Complications

Abstract Background Prevention of hemorrhagic complications has emerged as a priority in patients undergoing Percutaneous Coronary Intervention (PCI) in addition to suppressing thrombotic complications. This goal is challenging to achieve in diabetic Acute Coronary Syndrome (ACS) patients as Diabetes Mellitus (DM) itself is a prothrombotic state with more pronounced vascular injury response and have a worse outcome after PCI compared with non-diabetic patients. In patients with ACS, Bivalirudin has been shown to result in similar rates of composite ischemia as Heparin plus GPI (GP IIb /IIIa inhibitor), while significantly reducing major bleeding and has received class I recommendation for PCI by American College of Cardiology (ACC 2013). Whether Bivalirudin is safe and effective specially in diabetic ACS patients undergoing PCI, as compared with Heparin (UFH) monotherapy, is unknown. Purpose To determine and compare the incidence of in-hospital and 30-day hemorrhagic complications and major adverse cardiac events (MACEs) as evidence of safety and efficacy using Bivalirudin versus Heparin in diabetic ACS patients undergoing PCI. Methods 218 diabetic ACS patients (age>18 years and ≤75 years) who underwent PCI from May 2018 to April 2019 at University Cardiac Centre, BSM Medical University, Dhaka, Bangladesh were randomly assigned to have UFH or Bivalirudin. Before the guide wire crossed the lesion, 111 patients in the UFH group received a bolus of 70–100 U/kg (targeted activated clotting time, ACT: 200–250 s). 107 patients in the Bivalirudin group received a loading dose of 0.75 mg/kg, followed by an infusion of 1.75 mg/kg/h for up to 4 hours. Dual antiplatelet (DAPT) loading as Aspirin 300 mg plus P2Y12 inhibitors (Clopidogrel 600 mg or Prasugrel 60 mg or Ticagrelor 180 mg) was given in all patients before the procedure. The maintenance dose of DAPT was continued for at least one month and patients were followed telephonically up to 30 days. The outcome measures were in-hospital and 30-day hemorrhagic complications and MACEs [death, MI, target vessel revascularization (TVR) and stroke]. Results Patients treated with Bivalirudin compared with Heparin had a significantly lower in-hospital incidence of QMI (0% vs. 6%; p=0.03) and major bleeding (0% vs. 7%; p=0.02). However, the incidence of cardiac death, stent thrombosis, TVR were no differences between two groups (p>0.05). There was only one NQMI in the Bivalirudin group as opposed to 8% in the Heparin group in 30 days following stenting (p=0.04). Conclusion In diabetic ACS patients undergoing PCI, Bivalirudin is safe and effective as it reduces immediate and short-term hemorrhagic complications as well as MACEs as compared with Heparin. FUNDunding Acknowledgement Type of funding sources: None.

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Personalized Antiplatelet Therapy Based on CYP2C19 Genotypes in Chinese ACS Patients Undergoing PCI: A Randomized Controlled Trial

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.676954 ◽

2021 ◽

Vol 8 ◽

Author(s):

Xiujin Shi ◽

Yunnan Zhang ◽

Yi Zhang ◽

Ru Zhang ◽

Baidi Lin ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Confidence Interval ◽

Antiplatelet Therapy ◽

Primary Endpoint ◽

Coronary Intervention ◽

Chinese Patients ◽

Bleeding Events ◽

Coronary Syndrome ◽

Percutaneous Coronary

Background: The clinical benefits of cytochrome P450 (CYP) 2C19 genotype-guided antiplatelet therapy in Asians remain unclear. In this study, we aimed to investigate the clinical outcomes of pharmacogenomic antiplatelet therapy in Chinese patients.Methods: Patients with acute coronary syndrome planning to undergo percutaneous coronary intervention were eligible for this study and were randomly divided into a genotype-guided treatment (GT) group and routine treatment (RT) group, with a ratio of 2:1. Patients in the GT group underwent CYP2C19 genotyping (*2 and *3 alleles), and the results were considered in selecting P2Y12 receptor inhibitors. Patients in the RT group were treated with P2Y12 receptor inhibitors according to their clinical characteristics. The primary endpoint was a composite of major adverse cardiovascular or cerebrovascular events (MACCE). The secondary endpoint was significant bleeding events.Results: Finally, 301 patients were enrolled; 75.1% were men and the mean age was 59.7 ± 9.8 years. In total, 281 patients completed the follow-up procedure. The primary endpoint occurred in 16 patients, 6 patients in the GT group and 10 in the RT group. The GT group showed lower MACCE rates than the RT group (6/189 vs. 10/92, 3.2 vs. 10.9%, hazard ratio: 0.281, 95% confidence interval: 0.102–0.773, P = 0.009). There was no statistically difference in significant bleeding events between the GT and RT groups (4.2 vs. 3.3%, hazard ratio: 1.315, 95% confidence interval: 0.349–4.956, P = 0.685).Conclusion: Personalized antiplatelet therapy that is based on CYP2C19 genotypes could decrease MACCE within a 12-month period in Chinese patients with acute coronary syndrome undergoing percutaneous coronary intervention.Clinical Trial Registration:http://www.chictr.org.cn, identifier: ChiCTR2000034352.

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

Cardiovascular Therapeutics ◽

10.1155/2021/8836450 ◽

2021 ◽

Vol 2021 ◽

pp. 1-9

Author(s):

Zhongxiu Chen ◽

Zheng Liu ◽

Nan Li ◽

Ran Liu ◽

Miye Wang ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Platelet Count ◽

Major Bleeding ◽

Primary Outcome ◽

Coronary Intervention ◽

Hospital Death ◽

Hospital Inpatient ◽

Bleeding Events ◽

Coronary Syndrome ◽

Percutaneous Coronary

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 × 10 9 / 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 × 10 9 / 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.

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P2Y12 Inhibitor Monotherapy with Clopidogrel versus Ticagrelor in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Journal of Clinical Medicine ◽

10.3390/jcm9061657 ◽

2020 ◽

Vol 9 (6) ◽

pp. 1657

Author(s):

Po-Wei Chen ◽

Wen-Han Feng ◽

Ming-Yun Ho ◽

Chun-Hung Su ◽

Sheng-Wei Huang ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Primary Endpoint ◽

Major Bleeding ◽

Lower Risk ◽

Coronary Intervention ◽

P2y12 Inhibitor ◽

Coronary Syndrome ◽

Percutaneous Coronary ◽

All Cause Mortality

Background: P2Y12 inhibitor monotherapy is an alternative antiplatelet strategy in patients undergoing percutaneous coronary intervention (PCI). However, the ideal P2Y12 inhibitor for monotherapy is unclear. Methods and Results: We performed a multicenter, retrospective, observational study to compare the efficacy and safety of monotherapy with clopidogrel versus ticagrelor in patients with acute coronary syndrome (ACS) undergoing PCI. From 1 January 2014 to 31 December 2018, 610 patients with ACS who received P2Y12 monotherapy with either clopidogrel (n = 369) or ticagrelor (n = 241) after aspirin was discontinued prematurely were included. Inverse probability of treatment weighting was used to balance covariates between the groups. The primary endpoint was the composite of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months after discharge. Overall, 84 patients reached the primary endpoint, with 57 (15.5%) in the clopidogrel group and 27 (11.2%) in the ticagrelor group. Multivariate adjustment in Cox proportional-hazards models revealed a lower risk of the primary endpoint with ticagrelor than with clopidogrel (adjusted hazard ratio (aHR): 0.67, 95% confidence interval (CI): 0.49–0.93). Ticagrelor significantly reduced the risk of recurrent ACS or unplanned revascularization (aHR: 0.46, 95% CI: 0.28–0.75). No significant difference in all-cause mortality and major bleeding events was observed between the 2 groups. Conclusions: Among patients with ACS undergoing PCI who cannot complete course of dual antiplatelet therapy, a significantly lower risk of cardiovascular events was associated with ticagrelor monotherapy than with clopidogrel monotherapy. The major bleeding risk was similar in both the groups.

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Impact of infection in patients with non-ST elevation acute coronary syndrome undergoing percutaneous coronary intervention: insight from a multicentre observational cohort from China

BMJ Open ◽

10.1136/bmjopen-2020-038551 ◽

2020 ◽

Vol 10 (9) ◽

pp. e038551

Author(s):

Peng-Yuan Chen ◽

Yuan-Hui Liu ◽

Chong-Yang Duan ◽

Lei Jiang ◽

Xue-Biao Wei ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Major Bleeding ◽

Coronary Intervention ◽

Hospital Infection ◽

Coronary Syndrome ◽

Percutaneous Coronary ◽

Observational Cohort ◽

St Elevation

ObjectiveWe aimed to describe the association between in-hospital infection and prognosis among patients with non-ST elevation acute coronary syndrome (NSTE-ACS) who received percutaneous coronary intervention (PCI).DesignThis observational cohort originated from a database of patients with NSTE-ACS who underwent PCI from 1 January 2010 to 31 December 2014.SettingFive centres in South China.ParticipantsThis multicentre observational cohort study consecutively included 8197 patients with NSTE-ACS who received PCI. Only patients with adequate information to diagnose or rule out infection were included. Patients were excluded if they were diagnosed with a malignant tumour, were pregnant or presented with cardiogenic shock at the index date. Patients were grouped by whether they had in-hospital infection or not.Primary and secondary outcome measuresThe primary outcome was all-cause death and major bleeding during hospitalisation. The secondary outcomes included all-cause death and major bleeding during follow-up and in-hospital myocardial infarction.ResultsOf the 5215 patients, 206 (3.95%) acquired infection. Patients with infection had a higher rate of in-hospital all-cause death and major bleeding (4.4% vs 0.2% and 16.5% vs 1.2%, respectively; p<0.001). After adjusting for confounders, infection remained independently associated with in-hospital and long-term all-cause death (OR, 13.19, 95% CI 4.59 to 37.87; HR, 2.03, 95% CI 1.52 to 2.71; p<0.001) and major bleeding (OR, 10.24, 95% CI 6.17 to 16.98; HR, 5.31, 95% CI 3.49 to 8.08; p<0.001). A subgroup analysis confirmed these results.ConclusionsThe incidence of infection is low during hospitalisation, but is associated with worse in-hospital and long-term outcomes.

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Safety and Efficacy of Bivalirudin in Diabetic Acute Coronary Syndrome (ACS) Patients Undergoing Percutaneous Coronary Intervention (PCI)

European Journal of Medical and Health Sciences ◽

10.24018/ejmed.2021.3.2.768 ◽

2021 ◽

Vol 3 (2) ◽

pp. 93-97

Author(s):

A.B.M. Golam Mostofa ◽

Tanjima Parvin ◽

Mohammad Rayhan Masum Mandal ◽

Rawnak Afrin ◽

Syed Ali Ahsan

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Major Bleeding ◽

Coronary Intervention ◽

Controlled Study ◽

Small Scale ◽

Safety And Efficacy ◽

Coronary Syndrome ◽

Percutaneous Coronary ◽

Hemorrhagic Complications

Objective: To determine and compare the incidence of in-hospital and 30-day hemorrhagic complications and major adverse cardiac events (MACEs) as evidence of safety and efficacy using Bivalirudin versus Heparin in diabetic acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) in a tertiary care cardiac hospital. Background: Prevention of hemorrhagic complications has emerged as a priority in patients undergoing PCI in addition to suppressing thrombotic complications. This goal is challenging to achieve in diabetic ACS patients as DM itself is a prothrombotic state with more pronounced vascular injury response and have a worse outcome after PCI compared with non-diabetic patients. In patients with ACS, Bivalirudin has been shown to result in similar rates of composite ischemia as Heparin plus GPI (GP IIb /IIIa inhibitor), while significantly reducing major bleeding and has received class I recommendation for PCI. Whether Bivalirudin is safe and effective in diabetic ACS patients undergoing PCI, as compared with Heparin (UFH) monotherapy, is unknown. Methods: 218 diabetic ACS patients (age>18 years and ≤ 75 years) who underwent PCI from May 2018 to April 2019 at UCC, BSMMU, Dhaka, Bangladesh were randomly assigned to have UFH or Bivalirudin. Before the guide wire crossed the lesion, 111 patients in the UFH group received a bolus of 70-100 U/kg (targeted activated clotting time, ACT: 200-250 s). 107 patients in the Bivalirudin group received a loading dose of 0.75 mg/kg, followed by an infusion of 1.75 mg/kg/h for up to 4 hours. Dual antiplatelet (DAPT) loading as Aspirin 300 mg plus P2Y12 inhibitors (Clopidogrel 600 mg or Prasugrel 60 mg or Ticagrelor 180 mg) was given in all patients before the procedure. The maintenance dose of DAPT was continued for at least one month and patients were followed telephonically up to 30 days. The outcome measures were in-hospital and 30-day hemorrhagic complications and MACEs [death, MI, target vessel revascularization (TVR) and stroke]. Results: Patients treated with Bivalirudin compared with Heparin had a significantly lower in-hospital incidence of QMI (0% vs. 6%; p=0.03) and major bleeding (0% vs. 7%; p=0.02). However, the incidence of cardiac death, stent thrombosis, TVR were no differences between the groups (p>0.05). There was only one NQMI in the Bivalirudin group as opposed to 8% in the Heparin group in 30 days following stenting (p=0.04). No other adverse effects were found significantly different between groups in 30 days of PCI. Conclusion: In this small scale, prospective, randomized controlled study of diabetic ACS patients undergoing PCI in a single center showed that Bivalirudin is safe and effective as it reduces immediate and short-term hemorrhagic complications as well as MACEs as compared with Heparin.

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Changes of antithrombotic prescription in atrial fibrillation patients with acute coronary syndrome or percutaneous coronary intervention and the subsequent impact on long-term outcomes: A longitudinal cohort study

10.21203/rs.3.rs-518171/v1 ◽

2021 ◽

Author(s):

Chiao-Chin Lee ◽

Chiao-Hsiang Chang ◽

Yuan Hung ◽

Chin-Sheng Lin ◽

Shih-Ping Yang ◽

...

Keyword(s):

Atrial Fibrillation ◽

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Cohort Study ◽

Major Bleeding ◽

Antithrombotic Therapy ◽

Coronary Intervention ◽

Prescription Rate ◽

Coronary Syndrome ◽

Percutaneous Coronary

Abstract Objectives:The choice of optimal antithrombotic therapy in atrial fibrillation (AF) patients with acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) remains controversial. The aim of this longitudinal cohort study is to investigate the prescribing pattern of antithrombotic regimen in different cohorts and its subsequent impact. Setting and Design:Longitudinal data from the Tri-Service General Hospital-Coronary Heart Disease (TSGH-CHD) registry, between January 2016 and August 2018 was screened. Participants and method:Patients with prior history of nonvalvular AF, who had ACS presentation or had underwent PCI were selected, and these patients were divided into cohort 1 and cohort 2, according to the index date of antithrombotic prescription before and after the PIONEER AF-PCI study.Primary and secondary outcomes:The primary safety endpoints were composites of major bleeding and/or clinically relevant non-major bleeding. The secondary efficacy endpoints included the occurrence of all-cause mortality, stroke/systemic embolization, nonfatal myocardial infarction (MI), and >30-days coronary revascularization. Results:A total of 121 patients were included into analysis (cohort 1=35; cohort 2=86). Comparing with cohort 1, the prescription rate of triple antithrombotic therapy (TAT) increased from 17.1% to 38.4%, especially the regimen with dual antiplatelet therapy (DAPT) plus low-dose non-vitamin-K dependent oral anticoagulation (NOAC). However, the prescription rate of dual antithrombotic therapy (DAT) decreased (14.3% to 10.5%), as well as the prescription rate of DAPT (68.6% to 51.2%). These changes of antithrombotic prescription across different cohorts were not associated with risk of adverse safety (HR= 0.87; 95% CI, 0.42-1.80, p=0.710) and efficacy outcomes (HR=0.96; 95% CI, 0.40-2.32, p=0.930). Conclusions: Entering the NOAC era, the prescription of TAT increased alongside the decrease in DAT. As the prescription rate of DAPT without anticoagulation remained high, future efforts are mandatory to improve the implementation of guidelines and clinical practice.

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