Perioperative management of oral antiplatelet therapy and clinical outcomes in coronary stent patients undergoing surgery

SummaryThe aim was to investigate the perioperative risk of ischaemic and bleeding events in patients with coronary stents undergoing cardiac and non-cardiac surgery and how these outcomes are affected by the perioperative use of oral antiplatelet therapy. This was a multicentre, retrospective, observational study conducted in patients with coronary stent(s) undergoing cardiac or non-cardiac surgery. The primary efficacy endpoint was the 30-day incidence of major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction (MI) or stroke. The primary safety endpoint was the 30-day incidence of Bleeding Academic Research Consortium (BARC) bleeding ≥ 2. A total of 666 patients were included. Of these, 371 (55.7 %) discontinued their antiplatelet medication(s) (all or partly) before undergoing surgery. At 30 days, patients with perioperative discontinuation of antiplatelet therapy experienced a significantly higher incidence of MACE (7.5 % vs 0.3 %, p < 0.001), cardiac death (2.7 % vs 0.3 %, p=0.027), and MI (4.0 % vs 0 %, p < 0.001). After adjustment, peri-operative antiplatelet discontinuation was the strongest independent predictor of 30-day MACE (odds ratio [OR]=25.8, confidence interval [CI]=3.37–198, p=0.002). Perioperative aspirin (adjusted OR 0.27, 95 % CI 0.11–0.71, p=0.008) was significantly associated with a lower risk of MACE. The overall incidence of BARC ≥ 2 bleeding events at 30-days was significantly higher in patients who discontinued oral antiplatelet therapy (25.6 % vs 13.9 %, p < 0.001). However, after adjustment, antiplatelet discontinuation was not independently associated with BARC ≥ 2 bleeding. In conclusion antiplatelet discontinuation increases the 30-day risk of MACE, in patients with coronary stents undergoing cardiac and non-cardiac surgery, while not offering significant protection from BARC≥ 2 bleeding.

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Abstract 15502: Clinical Outcomes in Patients Undergoing Non-cardiac Surgery Within 1 Year of Pci

Circulation ◽

10.1161/circ.142.suppl_3.15502 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Davide Cao ◽

Matthew A Levin ◽

Samantha Sartori ◽

Anastasios Roumeliotis ◽

Rishi Chandiramani ◽

...

Keyword(s):

Cardiac Surgery ◽

Antiplatelet Therapy ◽

Care Center ◽

Tertiary Care ◽

Coronary Intervention ◽

Secondary Outcome ◽

Cardiac Events ◽

Bleeding Events ◽

Target Vessel Revascularization ◽

Increased Risk

Introduction: Perioperative cardiovascular events are an important cause of morbidity and mortality associated with non-cardiac surgery (NCS), especially in patients with recent percutaneous coronary intervention (PCI) who require dual antiplatelet therapy. Objective: To illustrate the types and timing of different noncardiac surgeries occurring within 1 year of PCI, and to evaluate the risk of thrombotic and bleeding events according to perioperative antiplatelet management. Methods: All patients undergoing NCS within 1 year of PCI at a tertiary-care center between 2011 and 2018 were included. The primary outcome was major adverse cardiac events (MACE; composite of death, myocardial infarction, stent thrombosis or target vessel revascularization). The key secondary outcome was major bleeding, defined as ≥2 units of blood transfusion. All outcomes were evaluated at 30 days after NCS. Results: A total of 1092 NCS (corresponding to 747 patients) were included and classified by surgical risk (low: 50.9%, intermediate: 38.4%, high: 10.7%) and priority (elective: 88.5%, urgent/emergent: 11.5%). High-risk and urgent/emergent surgeries tended to occur earlier post-PCI compared to low-risk and elective ones ( Figure-A ). The incidence of MACE and bleeding was time-dependent, with an increased risk in surgeries occurring in the first 6 months post-PCI ( Figure-B ). Perioperative antiplatelet cessation occurred in 487 (44.6%) NCS and was more likely for intermediate-risk procedures and after 6 months of PCI. There was no significant association between antiplatelet cessation and cardiac events. Conclusions: Among patients undergoing NCS within 1 year of PCI, the perioperative risk of MACE is inversely related to time from PCI. Preoperative interruption of antiplatelet therapy was observed in less than half of all cases and was not associated with an increased risk of cardiac events.

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Abstract 16570: Systemic Inflammation Alters the Bleeding-Ischemic Balance in High-Bleeding Risk Patients Undergoing Percutaneous Coronary Interventions

Circulation ◽

10.1161/circ.142.suppl_3.16570 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Johny Nicolas ◽

Davide Cao ◽

Bimmer E Claessen ◽

Mauro Chiarito ◽

Samantha Sartori ◽

...

Keyword(s):

Care Center ◽

Tertiary Care ◽

Academic Research ◽

Bleeding Risk ◽

Lesion Length ◽

Syntax Score ◽

Cardiac Events ◽

Bleeding Events ◽

Percutaneous Coronary ◽

High Bleeding Risk

Introduction: Prognosis in high-bleeding risk (HBR) patients after percutaneous coronary intervention (PCI) is largely dependent on risk of ischemic/bleeding events. Inflammation is known to increase the ischemic risk following PCI in the general population, yet its impact on HBR patients remains unknown. Hypothesis: We assessed the hypothesis that inflammation, as reflected by elevated high-sensitivity C - reactive protein (hsCRP), increases the risk of ischemic and bleeding events in HBR patients undergoing PCI. Methods: We included patients who underwent PCI at a tertiary care center between 2014 and 2017. Patients were classified as HBR if they met ≥1 major or ≥2 minor criteria according to the Academic Research Consortium (ARC)-HBR consensus. Patients were then stratified into high (≥3 mg/l) and low (<3 mg/ml) baseline hsCRP level; those presenting with myocardial infarction (MI) or hsCRP >10 mg/l were excluded. The main outcomes of interest were major adverse cardiac events (MACE) (composite of all-cause death, MI, and target vessel revascularization) and bleeding events. Results: Out of 7,186 patients included, 3,403 (42.3%) fulfilled the ARC-HBR definition of whom 1,046 (34.4%) had high hsCRP. These patients were frequently female, younger, and had more cardiovascular risk factors (diabetes, kidney disease, and peripheral artery disease) yet similar angiographic features (multivessel disease, syntax score, and lesion length) than those with low hsCRP. Although risk of MACE at 1 year was similar in HBR patients with either high or low hsCRP, mortality risk was significantly higher in the former group ( Figure 1 ). In addition, HBR patients with high hsCRP were more likely to have periprocedural bleeding (OR 1.72, 95% CI [1.14-2.58], p=0.01) but similar risk of 1-year major bleeding as HBR patients with low hsCRP ( Figure 1 ). Conclusion: In conclusion, inflammation is associated with periprocedural bleeding and 1-year mortality in HBR patients undergoing PCI.

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Gastroscopy-related adverse cardiac events and bleeding complications among patients treated with coronary stents and dual antiplatelet therapy

Endoscopy International Open ◽

10.1055/s-0042-102649 ◽

2016 ◽

Vol 04 (05) ◽

pp. E527-E533 ◽

Cited By ~ 3

Author(s):

Gro Egholm ◽

Troels Thim ◽

Morten Madsen ◽

Henrik Sørensen ◽

Jan Pedersen ◽

...

Keyword(s):

Antiplatelet Therapy ◽

Dual Antiplatelet Therapy ◽

Coronary Stents ◽

Bleeding Complications ◽

Cardiac Events ◽

Adverse Cardiac Events

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Early stent thrombosis with bivalirudin in patients undergoing percutaneous coronary intervention

Thrombosis and Haemostasis ◽

10.1160/th14-08-0646 ◽

2015 ◽

Vol 113 (05) ◽

pp. 1010-1020 ◽

Cited By ~ 15

Author(s):

Raffaele Piccolo ◽

Chiara De Biase ◽

Carolina D’Anna ◽

Bruno Trimarco ◽

Federico Piscione ◽

...

Keyword(s):

Myocardial Infarction ◽

Percutaneous Coronary Intervention ◽

Stent Thrombosis ◽

Major Bleeding ◽

Meta Analysis ◽

Academic Research ◽

Coronary Intervention ◽

Bleeding Events ◽

Percutaneous Coronary ◽

Research Consortium

SummaryAlthough bivalirudin has been shown to reduce bleeding events in patients undergoing percutaneous coronary intervention, residual concerns remain about a possible higher risk of early (within 30 days) stent thrombosis (ST). Therefore, we performed a meta-analysis of randomised trials reporting ST events with bivalirudin compared to other antithrombotic therapies (heparins ± glycoprotein IIb/IIIa inhibitors). A systematic literature search of electronic resources was performed through May, 2014. The primary endpoint was definite early ST, according to Academic Research Consortium criteria. Secondary endpoints included: all-cause death, myocardial infarction and major bleeding. A total of 11 trials, including 16,415 patients, were accrued. Compared to other regimens, bivalirudin significantly increased the risk of early ST (odds ratio [OR]=1.80; 95 % confidence interval [CI], 1.28 2.52; p=0.0007) and reduced the risk of major bleeding (OR [95 %CI]=0.64 [0.51 0.82], p=0.0003), with a comparable risk of mortality or myocardial infarction. The higher risk of early ST was mainly attributable to acute (OR [95 % CI] =4.33 [2.33 8.05], p < 0.001) than subacute (OR [95 % CI] =0.89 [0.53 1.50], p =0.67) ST events (p for interaction < 0.001). Non-fatal myocardial infarction was the most common presentation (83 %) of early ST events, while death occurred infrequently (about 5 %). In conclusion, in patients undergoing PCI, bivalirudin compared to heparins is associated with a higher risk of early ST, which is mainly related to more frequent acute events. Further studies are required to evaluate alternative strategies to mitigate this risk, without hampering the benefits derived from the reduction in bleeding events with bivalirudin.

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Perioperative management of antiplatelet therapy in patients undergoing non-cardiac surgery following coronary stent placement: a systematic review

Systematic Reviews ◽

10.1186/s13643-017-0635-z ◽

2018 ◽

Vol 7 (1) ◽

Cited By ~ 11

Author(s):

Christopher P. Childers ◽

Melinda Maggard-Gibbons ◽

Jesus G. Ulloa ◽

Ian T. MacQueen ◽

Isomi M. Miake-Lye ◽

...

Keyword(s):

Systematic Review ◽

Cardiac Surgery ◽

Antiplatelet Therapy ◽

Stent Placement ◽

Perioperative Management ◽

Coronary Stent

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P906Impact of aortic valve calcification severity on device success after trans catheter aortic valve replacement

European Heart Journal ◽

10.1093/eurheartj/ehz747.0502 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J Larroche ◽

L Panh ◽

T Lhermusier ◽

O Lairez ◽

V Bataille ◽

...

Keyword(s):

Multivariate Analysis ◽

Aortic Valve ◽

Academic Research ◽

Region Of Interest ◽

Hounsfield Unit ◽

Cardiac Events ◽

Consensus Document ◽

Contrast Enhanced ◽

Adverse Cardiac Events ◽

Research Consortium

Abstract The aim of this study was to determine whether CS, measured on the preoperative contrast enhanced multislice computed tomography (MSCT), is associated with Device Success (DS), Major Adverse Cardiac Events (MACE) and paravalvular leaks (PVL) after TAVR. Methods We included 352 consecutive patients who underwent TAVR with a preoperative standardized contrast enhanced MSCT. Valvular calcifications detection was defined by adding +100 Hounsfield Unit (HU) to mean HU determined by a Region Of Interest placed in the contrast enhanced ascending aorta. CS was then indexed to the aortic annulus surface (CSi). Endpoints were DS and 30-days MACE according to Valve Academic Research Consortium-2 consensus document, and PVL greater than or equal to grade 2. Results DS was obtained for 305 patients. In multivariate analysis, CS and CSi were negatively and independently associated with DS: OR=0.88, 95% CI 0.81–0.96, p=0.004; and OR=0.94, 95% CI 0.91–0.98, p=0.002 respectively. There was no association between MACE and CS (p=0,953) and CSi (p=0,757). PVL was positively associated with CS (p<0.001) and CSi (p<0.001). Multivariate analysis for device success Multivariate analysis for device success procedure Initial Model Final Model OR (95% CI) p OR (95% CI) p Age (years) 1.06 (1–1.12) 0.058 Size (cm) 1.02 (0.98–1.07) 0.26 Hypertension 0.35 (0.13–0.92) 0.033 0.34 (0.13–0.87) 0.024 Diabete mellitus 1.72 (0.68–4.34) 0.249 Mean gradient 0.99 (0.97–1.02) 0.517 Mitral regurgitation 0.6 (0.28–1.27) 0.18 Valve size ≤23 1 (REF) 26 1.85 (0.8–4.27) 0.152 29 4.08 (1.32–12.59) 0.015 4.72 (1.62–13.78) 0.004 31 1.42 (0.32–6.38) 0.647 CS (for an increase of 1000 pts) 0.89 (0.81–0.98) 0.017 0.88 (0.81–0.96) 0.004 CSi (for an increase of 100 pts) 0.94 (0.9–0.99) 0.013 0.96 (0.91–0.98) 0.002 Example of CS measurement Conclusion In TAVR, the aortic valvular CS, measured on preoperative contrast enhanced MSCT, is significantly associated with DS and PVL, but not with 30-days MACE. Its routine use could be relevant to appreciate success chances of TAVR.

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Abstract 12614: Total Thrombus Formation Analysis System Can Predict High Bleeding Risk in Coronary Artery Disease Patients Undergoing Percutaneous Coronary Intervention

Circulation ◽

10.1161/circ.142.suppl_3.12614 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Nobuhiro Nakanishi ◽

Koichi Kaikita ◽

Kenichi Tsujita

Keyword(s):

Percutaneous Coronary Intervention ◽

Thrombus Formation ◽

Academic Research ◽

Bleeding Risk ◽

Coronary Intervention ◽

Bleeding Events ◽

Percutaneous Coronary ◽

Analysis System ◽

Research Consortium ◽

High Bleeding Risk

Introduction: Antithrombotic therapy is established for the treatment in various cardiovascular events, however, it has shown to increase the bleeding risk. Total Thrombus-formation Analysis System (T-TAS) is reported to be useful for evaluating thrombogenicity. Hypothesis: We examined whether T-TAS might predict 1-year bleeding risk in patients undergoing percutaneous coronary intervention (PCI). Methods: This was a retrospective, observational study at Kumamoto University Hospital between April 2017 and March 2019. Blood samples obtained on the day of PCI were used in T-TAS to compute the thrombus formation area under the curve (AUC) (AR10-AUC30, AUC for AR chip). We divided the study population into 2 groups according to the Academic Research Consortium for High Bleeding Risk (ARC-HBR) (182 patients in ARC-HBR positive, 118 in ARC-HBR negative). The primary endpoint was 1-year bleeding events that were defined by Bleeding Academic Research Consortium type2, 3, or 5. Results: The AR10-AUC30 levels were significantly lower in the ARC-HBR positive group than in the ARC-HBR negative group (median [interquartile range] 1568.1 [1258.5-1744.1] vs. 1723.1 [1567.0-1799.5], p<0.001). The combination of ARC-HBR and AR10-AUC30 could discriminate the bleeding risk, and improved predictive capacity compared with ARC-HBR by c-statistics and integrated discrimination improvement. In multivariate Cox hazards analyses, combining ARC-HBR and lower AR10-AUC30 levels were significantly associated with 1-year bleeding events. Decision curve analysis revealed that combining AR10-AUC30 with ARC-HBR ameliorated risk-prediction of bleeding events. Conclusions: The results highlighted that AR10-AUC30 could be a potentially useful marker for predicting high bleeding risk in patients undergoing PCI.

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