PracticeUpdate: Cardiology

CORONARY HEART DISEASE

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Chronic oral anticoagulation and associated outcomes in patients undergoing PCI

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.

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

Comment by Deepak L Bhatt MD, MPH, FACC, FAHA, FSCAI, FESC

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.

Use of chronic oral anticoagulation and associated outcomes among patients undergoing percutaneous coronary intervention Journal of the American Heart Association TAKE-HOME MESSAGE

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. 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. 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).

• 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

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

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.

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 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 Retinal vessel calibers in predicting long-term cardiovascular outcomes: the Atherosclerosis Risk in Communities Study Circulation Take-home message 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

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.

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)

• 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

have been associated with negative cardiovascular outcomes. We investi- gated whether retinal vessel calibers

BACKGROUND Narrower retinal ar- terioles and wider retinal venules

PRACTICEUPDATE CARDIOLOGY