Outcomes Following Percutaneous Coronary Intervention Before, During, and After Transition to a Default Transradial Approach at a Veterans Affairs Medical Center

Transradial coronary intervention (TRI) lowers bleeding and mortality compared with transfemoral coronary intervention (TFI). There are limited data on outcomes as TFI operators transition to a default TRI practice. The aim of this study was to assess TFI and TRI outcomes before, during, and after the year TRI was first learned by femoral operators. Patients undergoing percutaneous coronary intervention (PCI) at a Veterans Affairs Medical Center from 2006 to 2012 were included. In 2009, TRI was learned by all operators and then used as the default PCI approach from 2010 to 2012. Baseline characteristics and outcomes were collected. Predictors of major bleeding, major adverse cardiovascular events (MACE), and mortality were determined by multivariable analysis; 1192 veterans were included. TRI rates were 9% (2006-2008), 65% (2009), and 90% (2010-2012). Incidence of 1-year MACE and mortality was 5.4% and 3.9%, respectively, in 2009, and 5.6% and 3%, respectively, during 2010 to 2012. Major bleeding remained at <1%. Age, glycoprotein IIb/IIIa inhibitors, and ST-elevation myocardial infarction were independently associated with major bleeding, whereas TRI was protective. Transition to default TRI is feasible over a short time period and associated with low rates of MACE and mortality and very low rate of major bleeding.

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Are glycoprotein inhibitors safe during percutaneous coronary intervention in patients on chronic warfarin treatment?

Thrombosis and Haemostasis ◽

10.1160/th09-04-0245 ◽

2009 ◽

Vol 102 (12) ◽

pp. 1227-1233 ◽

Cited By ~ 21

Author(s):

Heli Lahtela ◽

Pasi Karjalainen ◽

Matti Niemelä ◽

Saila Vikman ◽

Kari Kervinen ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Major Bleeding ◽

Cardiovascular Events ◽

Warfarin Therapy ◽

Multivariable Analysis ◽

Coronary Intervention ◽

Major Adverse Cardiovascular Events ◽

Bleeding Events ◽

Hospital Variation ◽

Percutaneous Coronary

SummaryThe aim of this study was to evaluate the safety of glycoprotein IIb/IIIa inhibitors (GPIs) during percutaneous coronary intervention (PCI) in patients on chronic warfarin therapy due to atrial fibrillation (AF).We analysed all consecutive AF patients (N = 377, mean age 70 years, male 71%) on warfarin therapy referred for PCI in seven centres. Major bleeding, access site complications and major adverse cardiovascular events were recorded during hospitalisation. A total of 111 patients (29%) received periprocedural GPIs with a wide inter-hospital variation in their use (range 3–68%).The use of GPIs increased with the severity of the disease presentation and 49% of patients with ST-elevation myocardial infarction received GPIs. Mean periprocedural international normalised ratio (INR) of patients who received GPIs was 1.89 (range 1.1–3.3). Major bleeding was more common in the patients treated with GPIs (9.0% vs. 1.5%, p = 0.001) than in those without GPIs, but there was no difference in major adverse cardiovascular events between the groups. In multivariable analysis, use of GPIs (odds ratio [OR]???????????5.1, 95% confidence interval [CI]???????????1.3–20.6, p = 0.02) and old age (OR 1.2, 95% CI 1.0–1.3, p = 0.02) remained as the only independent predictors of major bleeding. Also after adjusting for propensity score, GPIs remained as a significant predictor of major bleeding (OR 3.8, 95% CI 1.03–14.1, p = 0.045). In the GPI group, major bleeding was not predicted by INR level or warfarin pause. GPIs increase the risk of major bleeding events irrespective of periprocedural INR levels and should be used with caution in this fragile patient group.

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Is percutaneous coronary intervention safe during uninterrupted direct oral anticoagulant therapy in patients with atrial fibrillation and acute coronary syndromes?

Open Heart ◽

10.1136/openhrt-2021-001677 ◽

2021 ◽

Vol 8 (2) ◽

pp. e001677

Author(s):

Leonardo De Luca ◽

Andrea Rubboli ◽

Leonardo Bolognese ◽

Massimo Uguccioni ◽

Donata Lucci ◽

...

Keyword(s):

Atrial Fibrillation ◽

Percutaneous Coronary Intervention ◽

Acute Coronary Syndromes ◽

Multivariable Analysis ◽

Coronary Intervention ◽

Major Adverse Cardiovascular Events ◽

Safe Procedure ◽

Percutaneous Coronary ◽

Coronary Syndromes

ObjectivesNo data on optimal management of patients with acute coronary syndromes (ACS) on long-term direct oral anticoagulants (DOACs) undergoing percutaneous coronary intervention (PCI) are available. Using the data of the Management of Antithrombotic TherApy in Patients with Chronic or DevelOping AtRial Fibrillation During Hospitalization for PCI study, we sought to compare the outcome of patients with ACS and atrial fibrillation (AF) who underwent PCI during uninterrupted DOAC (UDOAC group) and those who interrupted DOAC before PCI (IDOAC group).MethodsThe primary outcomes of our analysis were the incidence of major adverse cardiovascular events (MACEs), a composite of death, cerebrovascular events, recurrent myocardial infarction or revascularisation and net adverse clinical events (NACEs), including major bleeding, at 6 months.ResultsAmong the 132 patients on long-term DOAC, 72 (54.6%) underwent PCI during UDOAC and 60 (45.4%) after IDOAC. The mean CHA2DS2-VASc score was 3.8±1.7 and 3.9±1.3 (p=0.89), while the HAS-BLED score was 2.5±1.0 and 2.5±0.9 (p=0.96), in UDOAC and IDOAC groups, respectively. The median time from hospital admission to PCI was 9.5 (IQR: 2.0–31.5) hours in UDOAC and 45.5 (IQR: 22-5–92.0) hours in IDOAC group (p<0.0001). A radial approach was used in 92%, and a drug-eluting stent was implanted in 98% of patients. At 6 months, the rates of MACE (13.9% vs 16.7%) and NACE (20.8% vs 21.7%) did not differ between UDOAC and IDOAC groups. At multivariable analysis, increasing CHA2DS2-VASc score (HR: 1.39; 95% CIs 1.05 to 1.83; p=0.02) resulted as the only independent predictor of NACE.ConclusionsOur study shows that PCI is a safe procedure during UDOAC in patients with concomitant ACS and AF.

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Comparing prasugrel to twice daily clopidogrel post percutaneous coronary intervention in a Veterans Affairs population

American Journal of Health-System Pharmacy ◽

10.2146/sp150017 ◽

2015 ◽

Vol 72 (17_Supplement_2) ◽

pp. S98-S103 ◽

Cited By ~ 2

Author(s):

Samreen Khatri ◽

Tamra Pierce

Keyword(s):

Percutaneous Coronary Intervention ◽

Platelet Reactivity ◽

Medical Center ◽

Coronary Intervention ◽

Veterans Affairs ◽

Cardiovascular Outcomes ◽

Bleeding Events ◽

Daily Group ◽

Percutaneous Coronary ◽

Study Results

Abstract Objective The purpose of this study was to compare various antiplatelet regimens in patients who experienced increased platelet reactivity on clopidogrel therapy with regards to cardiovascular outcomes, including need for revascularization, myocardial infarction (MI), stroke, and cardiovascular (CV) death. Methods A retrospective chart review was conducted on patients who received percutaneous coronary intervention (PCI) at the Richard L. Roudebush Veterans Affairs Medical Center and were subsequently prescribed either clopidogrel 75 mg twice daily, prasugrel 10 mg daily, or clopidogrel 75 mg daily with high platelet reactivity between October 1, 2009 and November 30, 2010. Correlations between antiplatelet regimens and prevention of cardiovascular outcomes and bleeding events were evaluated. Groups were evaluated statistically as two separate comparisons; the first comparison being clopidogrel twice daily versus prasugrel and the second comparison being clopidogrel twice daily versus clopidogrel daily in those patients with a P2Y12 test result of less than 50%. Results A total of 108 patients were included in the study. Eight events occurred in the clopidogrel twice daily group (n = 26), including five revascularizations and three MIs. Seven events occurred in the prasugrel group (n = 64), including two revascularizations, two MIs, two strokes, and one CV death. The difference between these groups was statistically significant (p = 0.031), with patients in the prasugrel group experiencing fewer events. Five events occurred in the clopidogrel daily group (n = 18), including one need for revascularization, two MIs, and two instances of CV death. There were no statistically significant differences in CV events between the clopidogrel twice daily group and clopidogrel daily group (p > 0.999). There were also no statistically significant differences in bleeding incidents for either of the comparisons; p > 0.999 and p = 0.676 respectively for the first and second comparisons. Conclusion Patients on prasugrel had fewer cardiovascular events as compared to patients on clopidogrel twice daily with no difference in bleeding events. No difference was seen with regards to cardiovascular or bleeding events when comparing clopidogrel twice daily to clopidogrel daily in patients with increased platelet reactivity. Study results suggest that there is no benefit to dosing clopidogrel twice daily when compared to either prasugrel or once daily clopidogrel dosing.

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Switching to Clopidogrel in Patients With Acute Coronary Syndrome Managed With Percutaneous Coronary Intervention Initially Treated With Prasugrel or Ticagrelor: Systematic Review and Meta-analysis

Annals of Pharmacotherapy ◽

10.1177/1060028019845334 ◽

2019 ◽

Vol 53 (10) ◽

pp. 997-1004 ◽

Cited By ~ 1

Author(s):

Jenny Hong ◽

Ricky D. Turgeon ◽

Glen J. Pearson

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Major Bleeding ◽

Meta Analysis ◽

Coronary Intervention ◽

Secondary Outcome ◽

Major Adverse Cardiovascular Events ◽

Case Control Studies ◽

Coronary Syndrome ◽

Percutaneous Coronary

Objective: To evaluate the effects of switching from ticagrelor or prasugrel to clopidogrel in acute coronary syndrome (ACS) patients managed with percutaneous coronary intervention on major adverse cardiovascular events (MACEs) and bleeding. Data Sources: We searched MEDLINE, EMBASE, CENTRAL, bibliographies of relevant articles, and clinicaltrials.gov for eligible articles published from inception to January 27, 2019. Study Selection and Data Extraction: We included randomized controlled trials (RCTs) and cohort and case-control studies that reported on ≥1 outcome of interest. Primary outcomes were MACE and major bleeding, and the secondary outcome was any bleeding. Data Synthesis: From 483 articles, we included 7 relevant studies (2 RCTs, 5 cohort studies) at high/unclear risk of bias. Random-effects meta-analysis revealed inconclusive effects on MACE (hazard ratio [HR] = 1.00, 95% CI = 0.59-1.68; I2 = 82%), major bleeding (HR = 0.51; 0.19-1.35; I2 = 91%), and any bleeding (HR = 0.64; 0.38-1.07; I2 = 85%). Similar nonsignificant results were obtained in secondary analyses evaluating risk ratios. Relevance to Patient Care and Clinical Practice: Ticagrelor and prasugrel, are now considered preferred therapy over clopidogrel in patients with ACS. Switching from these potent P2Y12 inhibitors to clopidogrel is commonly performed to reduce bleeding risk, other adverse effects, or costs. Current best-available evidence is inconclusive regarding the effects of switching to clopidogrel on the risk of MACE and bleeding. Overall, studies were underpowered to detect clinically important differences. Conclusions: Until adequately powered trials demonstrate an advantage to switching to clopidogrel from prasugrel or ticagrelor, clinicians may consider this approach as clinically indicated on an individual, case-by-case basis.

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