Juan M. Ruiz-Nodar

Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implications for bleeding risk and prognosis.

OBJECTIVES This study was designed to review outcomes in relation to antithrombotic therapy management strategies for patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) with stenting. BACKGROUND There is limited evidence on the optimal antithrombotic therapy management strategies for patients with AF who undergo PCI with stenting. METHODS We reviewed 426 patients (70.9% men, mean age 71.5 +/- 8.5 years) with AF undergoing PCI with stenting between 2001 and 2006. We recorded clinical and demographic characteristics of the patients, stroke risk factors, and antithrombotic therapy use before PCI and at discharge. Clinical follow-up was performed, and all bleeding episodes, thromboembolism, and major adverse cardiac events (MACE) (i.e., death, acute myocardial infarction, or target lesion revascularization) were recorded. RESULTS The most commonly associated comorbidities were hypertension (74.5%), diabetes mellitus (40.2%), chronic renal failure (14.9%), and congestive heart failure (26.7%); 80% of patients had >or=2 stroke risk factors. Of the drugs prescribed at discharge, aspirin plus clopidogrel were used in 174 patients (40.8%), whereas 213 patients (50%) were discharged with triple therapy (coumarins, aspirin, and clopidogrel). Complete follow-up was achieved in 87.5% (median 594 days; range 0 to 2,190). The incidence of adverse events was high (36.6%), with major bleeding in 12.3%, thromboembolic events in 4.2%, and MACE in 32.3%. All-cause mortality was high (22.6%). In a multivariate analysis, non-anticoagulation with coumarins increased mortality (17.8% vs. 27.8%; hazard ratio [HR] = 3.43; 95% confidence interval [CI] 1.61 to 7.54; p = 0.002) and MACE (26.5% vs. 38.7%; HR = 4.9; 95% CI 2.17 to 11.1; p < 0.01) In a Cox-regression analysis, non-anticoagulation (p < 0.01) and age (p = 0.02) were independent predictors of MACE. CONCLUSIONS Patients with AF undergoing PCI with stenting represent a high-risk population because of age, comorbidities, and presence of stroke risk factors. These patients have a high mortality and MACE rate, which is reduced by anticoagulation therapy.

Should We Recommend Oral Anticoagulation Therapy in Patients With Atrial Fibrillation Undergoing Coronary Artery Stenting With a High HAS-BLED Bleeding Risk Score?

Background— Recent European guidelines for the management of atrial fibrillation recommend oral anticoagulation (OAC) in patients with CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years, diabetes, history of previous stroke, vascular disease, age 65–74 years, and sex category [female]) ≥1. The HAS-BLED score (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly [>65 years], Drugs/alcohol concomitantly) has been suggested to assess bleeding risk in patients with atrial fibrillation (score ≥3 indicates high risk of bleeding). Despite the guidelines, this approach has never been tested in a cohort of patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation. Methods and Results— We studied 590 consecutive patients with atrial fibrillation undergoing percutaneous coronary intervention/stenting and CHA2DS2-VASC score >1 (ie, OAC recommended). We compared patients with low-intermediate bleeding risk (HAS-BLED 0–2) and high risk (HAS-BLED ≥3), the relation between CHA2DS2-VASC and HAS-BLED, and the benefit and risks of the use of OAC in patients with high bleeding risk. The development of any bleeding episode, thromboembolism, mortality, cardiac events, and the composite major adverse cardiac events (ie, death, acute myocardial infarction, and/or target lesion revascularization) end point was recorded as well as the composite major adverse events (ie, major adverse cardiac events, major bleeding, or thromboembolism) end point at 1-year follow-up. Of the study cohort, 420 (71%) had a HAS-BLED score ≥3, and patients who were on OAC at discharge had lower mortality rate (9.3% versus 20.1%; P<0.01) and major adverse cardiac events (13.0% versus 26.4%; P<0.01) but with a similar major adverse event (20.5% versus 27.6%; P=0.11) and higher major bleeding rate (11.8% versus 4.0%; P<0.01). In a Cox multivariable analysis in patients with HAS-BLED ≥3, predictors of increased death were chronic renal failure and heart failure (both P<0.05), whereas OAC at discharge was associated with a reduced death rate (P<0.01). Predictors of major bleeding were chronic renal failure and the use of drug-eluting stents (both P<0.05). Conclusions— Most patients with atrial fibrillation undergoing percutaneous coronary intervention/stenting have a high risk for major bleeding (HAS-BLED score ≥3). Even in these patients, OAC improves prognosis in these patients (reduced mortality and major adverse cardiac events) with an increase in major bleeding.

Efficacy and safety of drug-eluting stent use in patients with atrial fibrillation

AIMS Drug-eluting stents (DES) have never been sufficiently studied in patients with atrial fibrillation (AF). The latter are considered as a high-risk population with uncertainty over the optimal antithrombotic therapy strategy to prevent stroke, stent thrombosis, and recurrent cardiac ischaemia, balanced against the high risk of haemorrhage. The aim of this study was to evaluate the safety and efficacy of the use of DES vs. bare-metal stents (BMS) in a cohort of patients with AF. METHODS AND RESULTS We reviewed 604 patients with AF who had undergone percutaneous coronary intervention with stent over a period of 7 years (January 2001-January 2008). After a propensity score selection, we identified two matched cohorts who received DES (n = 207) or BMS (n = 207). Clinical follow-up was performed, and all bleeding episodes, thrombo-embolism, and major adverse cardiac events (MACE; i.e. death, acute myocardial infarction, target vessel failure) were recorded. Complete follow-up was achieved in 95.9% of the cohort (mean: 693 +/- 427 days, median: 564). The incidence density of MACE as well as the incidence of all-cause mortality in both groups was similar. There was a higher incidence of major bleeding in DES group (2.26 vs. 1.19 per 10 000 days of exposure; P = 0.03). In a multivariate analysis, age, chronic AF, chronic renal failure, and non-use of dicoumarin were predictors of MACE and of all-cause mortality. The use of DES was not a predictor of reduced events. CONCLUSION On the basis of this study, the routine use of DES in patients with AF does not seem to be justified. A higher risk of major bleeding with DES in comparison with BMS raises the possibility that DES should be limited to lesions or patients with a high risk of restenosis.

Impacto del tipo de hospital en el tratamiento y evolución de los pacientes con síndrome coronario agudo sin elevación del ST

Introduccion y objetivos Las guias de practica clinica del sindrome coronario agudo sin elevacion del ST (SCASEST) no valoran la infraestructura hospitalaria y la facilidad de acceso a la sala de hemodinamica. Este estudio analiza la influencia del tipo de hospital, con o sin sala de hemodinamica, en la forma de tratamiento de pacientes con SCASEST y su posible impacto en el pronostico a medio plazo. Metodos El GYSCA es un registro multicentrico (15 hospitales) que analiza la aplicacion de las guias en pacientes con SCASEST: 6 con sala de hemodinamica (hospitales centrales) y 9 sin hemodinamica (hospitales comarcales). Se realizo seguimiento clinico al alta y a los 3 y a los 12 meses. Resultados Se recluto a 1.133 pacientes consecutivos; 599 (52,9%) en hospitales centrales y 534 (47,1%) en hospitales comarcales. El uso de intervenciones de clase I fue mayor en los centrales (aspirina, clopidogrel, bloqueadores beta, IECA y estatinas; p Conclusiones Los pacientes que ingresan por SCASEST en hospitales que no disponen de sala de hemodinamica son tratados de forma menos invasiva y con un tratamiento farmacologico menos ajustado a lo recomendado en las guias. Junto con los conocidos factores predictivos del pronostico, el tipo de hospital puede tener un impacto adicional en la evolucion.

Miocardio rescatado tras angioplastia coronaria de rescate: cuantificación mediante resonancia magnética cardiaca

INTRODUCTION AND OBJECTIVES When fibrinolysis fails in patients with ST elevation myocardial infarction, they are referred for a rescue percutaneous coronary intervention (PCI). However, there is still no evidence of how much myocardium potentially at risk we can actually salvage after rescue PCI. METHODS Fifty consecutive patients. Cardiac magnetic resonance was performed within 6 days. Myocardial necrosis was defined by the extent of abnormal late enhancement, myocardium at risk by extent of edema, and the amount of salvaged myocardium by the difference between myocardium at risk and myocardial necrosis. Finally, myocardial salvage index (MSI) resulted from the fraction (area-at-risk minus infarct-size)/area-at-risk. RESULTS The mean time elapsed between pain onset and fibrinolitic agent administration was 176 ± 113 min; time lysis-rescue=PCI 209 ± 122 min; time pain onset-PCI = 390 ± 152 min. The area at risk was 37% ± 13% and infarct size 34.5% ± 13%. Salvaged myocardium was 3% ± 4% and MSI 9 ± 8. Salvaged myocardium and MSI were similar between patients with the artery open on arrival at the catheterization lab (Thrombolysis in Myocardial Infarction [TIMI] 3) and those with TIMI flow ≤ 2 (3.3% ± 3.6% and 8.2 ± 6.9 in TIMI 0-2 vs 3.0% ± 3.7% and 10.8 ± 10.9 in TIMI 3; P=.80 and 0.31, respectively). No significant difference was observed between patients who went through rescue PCI within a shorter time and those with longer delay times. CONCLUSIONS The myocardial salvage after rescue PCI quantified by cardiac magnetic resonance is very small. The long delay times between pain onset and the opening of the infarct-related artery with PCI are most probably the reason for such a minimal effect of rescue PCI.

An Evaluation of the CHADS2 Stroke Risk Score in Patients With Atrial Fibrillation Who Undergo Percutaneous Coronary Revascularization

BACKGROUND There are various schemas designed to stratify the risk of thromboembolism (TE) in patients with atrial fibrillation (AF), of which the CHADS(2) (congestive heart failure, hypertension, age ≥ 75 y, diabetes, stroke [doubled]) score is the most widely studied. We evaluated whether the CHADS(2) score was adequate for TE risk stratification while assessing cardiac risk in patients with AF revascularized with coronary artery stents. METHODS We reviewed 604 consecutive patients with AF treated with at least one stent between 2001 and 2008 in relation to TE risk using CHADS(2) score. We stratified our patients with a CHADS(2) score ≤ 1 as low-moderate thromboembolic risk (group 1: n = 193, 32%) and > 1 as high risk (and, hence, requiring anticoagulation; group 2: n = 411, 68%). We determined the benefits and/or risks of oral anticoagulation (OAC) therapy in both cohorts. RESULTS Completed follow-up was achieved in 90.4% (mean 642.2 days). Group 1 event-free survival was better than group 2 (major adverse cardiovascular events [MACEs], log-rank test P = .03; and death, log-rank test P = .03). In group 1, event-free survival was better on OAC vs non-OAC use (death 5% vs 15%, P = .04; MACE 10% vs 26%, P < .01) with a trend for more major hemorrhages (12% vs 4%, P = .08). Stroke rate was 4.1% per 100 patient-years in patients without OAC therapy and 1.38% in patients on OAC therapy. Group 2 had a lower incidence of death (20% vs 34%, P < .01) and MACE (26% vs 43%, P < .01) among those on OAC therapy on discharge, with a higher incidence of major hemorrhages (18% vs 8%, P < .01). CONCLUSION In a population of patients with AF revascularized with stents, even those with CHADS(2) ≤ 1 should be regarded as being at high risk. OAC should be considered as thromboprophylaxis in patients with AF revascularized with coronary stents.

Tratamiento antitrombótico y tipo de stent en pacientes con fibrilación auricular a los que se practica una intervención coronaria percutánea

Juan M. Ruiz-Nodar, Francisco Marı́n, and Gregory Y.H. Lip* a Servicio de Cardiologı́a, Hospital General Universitario de Alicante, Alicante, Spain b Servicio de Cardiologı́a, Hospital Universitario Virgen de la Arrixaca, Universidad de Murcia, El Palmar, Murcia, Spain Haemostasis, Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom

Oral anticoagulation improves the prognosis of octogenarian patients with atrial fibrillation undergoing percutaneous coronary intervention and stenting

BACKGROUND a significant proportion of octogenarian patients with atrial fibrillation (AF) undergo percutaneous coronary intervention (PCI) with stenting. Dual antiplatelet therapy is recommended in these patients, requiring a period of triple therapy with dual antiplatelet agent plus oral anticoagulation (OAC). Concerns remain regarding the appropriateness of OAC in octogenarians. METHODS we reviewed 604 patients (15.7% ≥80 years) with AF undergoing PCI. Clinical follow-up was performed, recording any bleeding episode, thrombo-embolism and major adverse cardiac events (MACE = death, acute myocardial infarction and/or revascularisation of target lesion). We compared octogenarian patients in relation to treatment with OAC at discharge. A secondary aim was to compare octogenarian patients with non-octogenarian patients in terms of their clinical and demographic characteristics, management and clinical outcome. RESULTS among the 604 patients, 95(15.7%) were aged ≥80 years. Octogenarians had a higher median CHADS2 score (2.78 versus 2.01; P < 0.001) and HAS-BLED score (3.05 versus 2.84; P = 0.028). After a follow-up of 17 ± 14 months, all-cause death occurred in 33%, MACE in 44%, and major bleeding in 21%. OAC was associated with less MACE (28.9 versus 58.3%; P = 0.012) and a similar rate of major bleeding. On multivariable analysis, non-use of OAC at discharge was associated with increased MACE (OR = 4.3; 95% CI = 1.3-14.6; P = 0.02). CONCLUSION octogenarian AF patients undergoing PCI/stenting have a high mortality rate and MACE, which can be reduced by means of OAC therapy.

Hipertensión arterial de bata blanca en ancianos. Análisis ecocardiográfico. Subestudio del proyecto EPICARDIAN

El objetivo fue evaluar las alteraciones ecocardiograficas en ancianos y analizar las diferencias entre normotensos, hipertensos de bata blanca e hipertensos permanentes. Los datos proceden de una submuestra del proyecto EPICARDIAN perteneciente al barrio de Lista (Madrid). De los 271 pacientes, 61 fueron clasificados como normotensos (22,5%); 81, como hipertensos de bata blanca (29,9%) y 129, como hipertensos permanentes (49,6%). El indice de masa del ventriculo izquierdo (IMV) segun los subgrupos fue 94,9 g/m2 (normotensos), 125,6 g/m2 (hipertensos de bata blanca) y 136,3 g/m2 (hipertensos mantenidos) (p < 0,001). La prevalencia de hipertrofia ventricular izquierda (HVI) por el criterio Deveraux fue del 13,2% (normotensos), el 49,1% (hipertensos de bata blanca) y el 54,3% (hipertensos permanentes) (p = 0,00007). La hipertension arterial de bata blanca en ancianos no es una situacion inocua, ya que su repercusion cardiaca se acerca mas a la de la hipertension permanente que a la de la normotension.

White-Coat Hypertension in the Elderly. Echocardiographic Analysis. A Substudy of the EPICARDIAN Project

The aims of this study were to investigate echocardiographic abnormalities in the elderly and to evaluate differences between those who are normotensive and those who have white-coat hypertension or sustained hypertension. The study used data on a subsample of participants in the EPICARDIAN project who came from the Lista district of Madrid, Spain. Of the 271 included, 61 (22.5%) were normotensive, 81 (29.9%) had white-coat hypertension and 129 (49.6%) had sustained hypertension. The left ventricular mass index was significantly different between the subgroups: 94.9 g/m2 in normotensives, 125.6 g/m2 in those with white-coat hypertension and 136.3 g/m2 in those with sustained hypertension (P< .001). The prevalence of left ventricular hypertrophy, defined using Deverauxs criteria, was 13.2% in normotensives, 49.1% in those with white-coat hypertension and 54.3% in those with sustained hypertension (P=.00007). White-coat hypertension is not a innocuous finding in the elderly because its implications for cardiac health are closer to those of sustained hypertension than to those of normal blood pressure.