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Chronic oral anticoagulation and associated outcomes in
patients undergoing PCI
Comment by Deepak L Bhatt
MD, MPH, FACC, FAHA, FSCAI, FESC
T
his observational study
found that approximately
9% of patients who had
recently undergone percutaneous
coronary intervention received oral
anticoagulants. Warfarin was the
predominant anticoagulant used
during the study period, but use
of the novel oral anticoagulants
increased in the later years of
the study. Not surprisingly, the
patients on oral anticoagulants
bled more than those who were
not on anticoagulants.
The PIONEER AF-PCI study
will be presented at the American
Heart Association and should
provide greater insight into the best
antithrombotic strategy for patients
with atrial fibrillation undergoing
stenting.
Dr Bhatt is Executive Director of
Interventional Cardiovascular
Programs at Brigham and
Women’s
Hospital Heart &
Vascular Center
and Professor
of Medicine
at Harvard
Medical School.
Calibre of retinal vessels as a marker
for cardiovascular risk
Comment by Sara B Seidelmann
MD, PhD, MS, MA, M.Phil
T
he cornea provides a transparent window
into the retinal microvasculature that
has been related to cardiovascular
outcomes. Whether retinal vessel calibre can
provide incremental value to current practice
guidelines (2013 AHA/ACC pooled cohort
equations [PCE]) in predicting atherosclerotic
cardiovascular disease events (ASCVE) hasn’t
been established. In 10,470 individuals,
narrower retinal arterioles and wider retinal
venules were associated with long-term risk
of mortality and ischaemic stroke in both
genders and coronary heart disease in women
independent of PCE risk-score variables.
Retinal vessel calibre reclassified 21% of low-
risk women (11% of all women) as having
intermediate-risk for ASCVE.
What are the clinical implications? The
identification of coronary heart disease is
frequently delayed or undiagnosed in women
and many at-risk for adverse outcomes are not
offered preventative or therapeutic options.
This under recognition may be partly due
to more prevalent non-obstructive coronary
heart disease in women, with microvascular
dysfunction largely contributing to myocardial
ischaemia. Whether adding retinal imaging to
further risk-stratify low-risk women will result
in the attenuation of risk for death or morbidity
from ASCVE in this group – which would be
unrecognised using current practice guidelines
– remains to be determined.
Use of chronic oral anticoagulation and associated outcomes among patients undergoing
percutaneous coronary intervention
Journal of the American Heart Association
TAKE-HOME MESSAGE
•
This retrospective evaluation of patients undergoing percutaneous coronary intervention (PCI)
compared the incidence of adverse events including major bleeding, access-site bleeding, stent
thrombosis, MI, stroke, and 90-day hospital readmission in patients receiving oral anticoagulant
(OAC) therapy with incidence in those patients not receiving OAC therapy. The study includes data
on both non–vitamin K antagonist agents and vitamin K antagonist agents. The results revealed that
the incidence for all adverse events related to PCI was higher in patients receiving OAC therapy.
•
The authors emphasize awareness regarding PCI risks in OAC-treated patients and recommend
diligence in improving measures to reduce these risks and improve safety in this population.
Abstract
BACKGROUND
Contemporary rates of oral antico-
agulant (OAC) therapy and associated outcomes
among patients undergoing percutaneous coronary
intervention (PCI) have been poorly described.
METHODS AND RESULTS
Using data from an integrated
health care system from 2009 to 2014, we identi-
fied patients on OACs within 30 days of PCI. Out-
comes included in-hospital bleeding and mortality.
Of 9566 PCIs, 837 patients (8.8%) were on OACs,
and of these, 7.9% used non–vitamin K antagonist
agents. OAC use remained stable during the study
(8.1% in 2009, 9.0% in 2014; P=0.11), whereas use of
non–vitamin K antagonist agents in those on OACs
increased (0% in 2009, 16% in 2014; P<0.01). Fol-
lowing PCI, OAC-treated patients had higher crude
rates of major bleeding (11% versus 6.5%; P<0.01),
access-site bleeding (2.3% versus 1.3%; P=0.017), and
non–access-site bleeding (8.2% versus 5.2%; P<0.01)
but similar crude rates of in-hospital stent thrombosis
(0.4% versus 0.3%; P=0.85), myocardial infarction
(2.5% versus 3.0%; P=0.40), and stroke (0.48% versus
0.52%; P=0.88). In addition, prior to adjustment, OAC-
treated patients had longer hospitalizations (3.9±5.5
versus 2.8±4.6 days; P<0.01), more transfusions (7.2%
versus 4.2%; P<0.01), and higher 90-day readmission
rates (22.1% versus 13.1%; P<0.01). In adjusted models,
OAC use was associated with increased risks of in-
hospital bleeding (odds ratio 1.50; P<0.01), 90-day
readmission (odds ratio 1.40; P<0.01), and long-term
mortality (hazard ratio 1.36; P<0.01).
CONCLUSIONS
Chronic OAC therapy is frequent
among contemporary patients undergoing PCI. After
adjustment for potential confounders, OAC-treated
patients experienced greater in-hospital bleeding,
more readmissions, and decreased long-term sur-
vival following PCI. Efforts are needed to reduce the
occurrence of adverse events in this population.
J AmHeart Assoc
2016 Oct 17;5:e004310, Secemsky
EA, Butala NM, Kartoun U, et al.
Retinal vessel calibers in predicting long-term cardiovascular outcomes:
the Atherosclerosis Risk in Communities Study
Circulation
Take-home message
•
This study investigated the association between long-term cardiovas-
cular outcomes and the caliber of retinal vessels in a cohort of 10,470
individuals. This clinical measurement was evaluated against the 2013
American College of Cardiology/American Heart Association pooled
cohort equations (PCE) in predicting atherosclerotic cardiovascular dis-
ease events. After a 16-year mean follow-up, a significant association
was found between presence of wider retinal venules or narrower retinal
arterioles and the rates of ischemic stroke (P < 0.0001 for both) and death
(P < 0.0001 for venules and P = 0.02 for arterioles). Rates of heart failure
were not associated with retinal vessel caliber. Interestingly, higher rates
of coronary heart disease were found in women with these retinal vessel
characteristics but not men (interaction P = 0.02). Of the low-risk female
participants (PCE, <5%), 21% would have been reassigned to intermediate-
risk (PCE, 5%–7.5%) as a result of the retinal measurements.
•
This study validates the incremental benefit of retinal vessel caliber
measurement for evaluating risk for ischemic stroke and death in the
general population. It appears to be of particular value in predicting risk of
coronary heart disease in women classified as low-risk by the 2013 PCE.
Abstract
BACKGROUND
Narrower retinal ar-
terioles and wider retinal venules
have been associated with negative
cardiovascular outcomes. We investi-
gated whether retinal vessel calibers
are associated with cardiovascular
outcomes in long-term follow-up and
provide incremental value over the
2013 American College of Cardiology/
American Heart Association pooled
cohort equations (PCE) in predicting
Atherosclerotic Cardiovascular Dis-
ease Events (ASCVE).
METHODS
10,470 men and women with-
out prior ASCVE or heart failure (HF) in
the Atherosclerosis Risk in Commu-
nities (ARIC) study underwent retinal
photography at visit 3 (1993–1995).
RESULTS
During a mean follow up of 16
years, there were 1779 incident CHD
events, 548 ischemic strokes, 1395 HF
events and 2793 deaths. Rates of all
outcomes were higher in those with
wider retinal venules and narrower
retinal arterioles. Subjects with wider
retinal venules [hazard ratio (HR) 1.13
(95% CI: 1.08-1.18), HR 1.18 (1.07–1.31)
and HR 1.10 (1.00–1.20) per standard
deviation (SD) increase] and narrower
retinal arterioles [HR 1.06 (1.01–1.11), HR
1.14 (1.03–1.26) and HR 1.13 (1.03–1.24)
per SD decrease] had a higher risk
of death and stroke in both sexes as
well as incident CHD in women but
not men (interaction p=0.02) after
adjustment for the PCE risk-score
variables. The association between
retinal vessel caliber and HF was non-
significant after adjustment for systolic
blood pressure. Among women with
PCE-predicted 10-year ASCVE risk
<5% (overall risk 3.9%), women in the
narrowest arteriolar quartile had a 10-
year event-rate of 5.6% compared to
2.8% for the widest quartile (5.0% vs
3.4% for wider vs narrower venules).
Retinal vessel caliber reclassified 21%
of low-risk women (11% of all women)
as intermediate-risk (>5%).
CONCLUSIONS
Narrower retinal arte-
rioles and wider retinal venules con-
ferred long-term risk of mortality and
ischemic stroke in both genders and
CHD in women. These measures serve
as an inexpensive, reproducible bio-
marker that added incremental value
to current practice guidelines in ASCVE
risk prediction in low-risk women.
Circulation
2016 Sep 28;[Epub
ahead of print], Seidelmann SB,
Claggett B, Bravo PE, et al.
JOURNAL SCAN
Shorter resuscitation time
associated with favorable
outcome following out-of-
hospital cardiac arrest
Circulation
Take-home message
•
The authors evaluated 11,368 individuals
with non-traumatic, EMS-treated out-
of-hospital cardiac arrest (OHCA)
in a single-blind randomized trial to
determine the impact of resuscitation
time on the probability of a favorable
outcome. Results showed that 35.4%
achieved a return of spontaneous
circulation, 10.8% survived to hospital
discharge, and 8% had survival to
hospital discharge with a favorable
outcome (modified Rankin scale, 0–3).
Of the people who had CPR up to 37
minutes in duration, 99% achieved
return of spontaneous circulation
(modified Rankin scale, 0–3), and
resuscitation time was associated with
survival to discharge after adjusting for
covariates (modified Rankin scale, 0–3).
•
In this large randomized trial of
individuals with EMS-treated OHCA,
a shorter resuscitation time was
associated with a favorable outcome
at hospital discharge.
Abstract
BACKGROUND
Little evidence guides the
appropriate duration of resuscitation in
out-of-hospital cardiac arrest (OHCA), and
case features justifying longer or shorter
durations are ill-defined. We estimated
the impact of resuscitation duration on the
probability of favorable functional outcome
in OHCA using a large, multi-center cohort.
METHODS
Secondary analysis of a North
American, single blind, multi-center, cluster-
randomized clinical trial (ROC-PRIMED)
of consecutive adults with non-traumatic,
EMS-treated, OHCA. Primary exposure was
duration of resuscitation in minutes (onset
of professional resuscitation to return of
spontaneous circulation [ROSC] or termination
of resuscitation). Primary outcome was
survival to hospital discharge with favorable
outcome (modified Rankin scale [mRS]
0–3). Subjects were additionally classified
as survival with unfavorable outcome (mRS
4–5), ROSC without survival (mRS 6), or
without ROSC. Subject accrual was plotted
as a function of resuscitation duration, and
the dynamic probability of favorable outcome
at discharge was estimated for the whole
cohort and subgroups. Adjusted logistic
regression models tested the association
between resuscitation duration and survival
with favorable outcome.
RESULTS
The primary cohort included
11,368 subjects (median age 69 years
[IQR: 56–81 years]; 7,121 men [62.6%]). Of
these, 4,023 (35.4%) achieved ROSC, 1,232
(10.8%) survived to hospital discharge, and
905 (8.0%) had mRS 0–3 at discharge.
Distribution of CPR duration differed by
outcome (p<0.00001). For CPR duration up
to 37.0 minutes (95%CI 34.9–40.9 minutes),
99% with eventual mRS 0–3 at discharge
achieved ROSC. Dynamic probability
of mRS 0–3 at discharge declined over
elapsed resuscitation duration, but subjects
with initial shockable cardiac rhythm,
witnessed cardiac arrest, and bystander
CPR were more likely to survive with
favorable outcome after prolonged efforts
(30–40 minutes). Adjusting for prehospital
(OR 0.93; 95%CI 0.92–0.95) and inpatient
(OR 0.97; 95%CI 0.95–0.99) covariates,
resuscitation duration was associated with
survival to discharge with mRS 0–3.
CONCLUSIONS
Shorter resuscitation duration
was associated with likelihood of favorable
outcome at hospital discharge. Subjects
with favorable case features were more
likely to survive prolonged resuscitation
up to 47 minutes.
The association between duration of
resuscitation and favorable outcome
after out-of-hospital cardiac arrest:
implications for prolonging or terminat-
ing resuscitation
Circulation
2016 Oct 19;[Epub ahead of
print], Reynolds JC, Grunau BE, Ritten-
berger JC, et al.
CORONARY HEART DISEASE
PRACTICEUPDATE CARDIOLOGY
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