CardioSource WorldNews December 2014 - Page 32

CLINICAL NEWS JOURNAL WRAP Kim Eagle, MD, and the editors of CardioSource present relevant articles from various journals Study Finds SiteLevel Variations in Post-PCI Bleeding There is wide variation in rates of post percutaneous coronary intervention (PCI) bleeding in the U.S., according to results of recent study; this variation remains despite adjustment for patient case-mix. Utilizing data from 1,292 National Cardiovascular Data Registry hospitals that performed > 50 PCI procedures from July 2009 to September 2012 (n = 1,984,998), outlier sites were identified based on 95% confidence intervals around the hospital’s random intercept. Bleeding 72 hours post-PCI was defined as follows: arterial access site, retroperitoneal, gastrointestinal, or genitourinary bleeding; intracranial hemorrhage; cardiac tamponade; nonbypass surgery-related blood transfusion with preprocedure hemoglobin ≥ 8 g/dl; or absolute decrease in hemoglobin value ≥ 3 g/dl with preprocedure hemoglobin ≤ 16 g/dl. Overall, the median unadjusted post-PCI bleeding rate was 5.2%; the rate varied among hospitals from 2.6% to 10.4%. Following case-mix adjustment, the center-level bleeding variation persisted. There was a modest association of hospital use of bleeding avoidance strategies (bivalirudin, radial access, or vascular closure device) with risk-adjusted bleeding rates. “Despite adjustment for patient case-mix, there is wide variation in rates of hospital PCI-related bleeding in the United States. Opportunities may exist for best performers to share practices with other sites,” the researchers concluded. In a Journal Scan analysis at Cardiosource.org, reviewer Hitinder S. Gurm, MBBS, said, “This study found that the widest variation in bleeding was seen with respect to 30 CardioSource WorldNews decline in hemoglobin of > 3 g/dL. This endpoint is most susceptible to variation in hydration status as well as ascertainment bias, and has the least clinical significance (compared with other components of the bleeding definition).” Hess CN, Rao SV, McCoy LA, et al. Circ Cardiovascular Qual Outcomes 2014;doi:10.1161/CIRCOUTCOMES.113.0007-49. Risk of AF and Stroke Increased in Patients with PAD Patients with peripheral artery disease (PAD) are at increased risk of atrial fibrillation (AF) and stroke, but the presence of AF do es not appear to mediate the risk of stroke in this population. Those were the primary findings of a study conducted by Wesley T. O’Neal, MD, MPH, and colleagues. The study included 6,568 participants enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA); mean age was 62 years, 53% were women, and 62% were nonwhite. Of the total study population, 12% (n = 774) had PAD at baseline. During follow-up (mean, 8.5 years), 4.6% (n = 301) developed AF and 2.1% (n = 140) had a stroke. Following adjustment for sociodemographics, cardiovascular risk factors, and potential confounders. There was an association of PAD with an increased risk of AF (HR = 1.5; 95% CI, 1.1 to 2.0). In a similarly adjusted model, PAD patients were at increased risk of developing stroke (HR = 1.7; 95% CI, 1.1 to 2.5). When AF was included as a time-dependent covariate, there was no change in the risk of stroke (HR = 1.7; 95% CI, 1.1 to 2.5). “PAD is associated with an increased risk of AF and stroke in MESA. Potentially, the relationship between PAD and stroke is not mediated by AF, ” the researchers said. Geoffrey D. Barnes, MD, cited the “It is surprising that approximately 30% of patients with AF Lack of OAC Therapy who had an IS Increases Risk of Secondary Events were discharged after IS for the hospital without OAC therapy.” study for Cardiosource.org. “This study serves as a reminder that atherosclerosis is a diffuse disease. Clinicians should consider evaluating all vascular beds as potential targets of atherosclerosis in PAD patients,” he said. O’Neal WT, Efird JT, Nazarian S, Alonso A, Heckbert SR, Soliman EZ. J Am Heart Assoc. 2014;doi:10.1161/JAHA.114.001270. According to results of a recent study of 2,162 consecutive patients with AF who were hospitalized for ischemic stroke (IS), 30% of patients with AF and recent IS were not given a prescription for any oral anticoagulant (OAC) on discharge. An additional 30% were prescribed combination OAC and antiplatelet therapy. Following discharge, 21.6% of patients were prescribed antiplatelet therapy alone, 39.3% were prescribed an OAC (warfarin) alone, 31.1% were prescribed a combination of OAC and antiplatelet therapy, and 8% were given no prescription for antithrombotic therapy. During a median follow-up of 3.3 years, the primary outcome (composite of death or hospitalization for recurrent IS, myocardial infarction, or major bleeding) occurred in 68% of patients. Following correction for confounding variables, compared with therapy with an OAC alone, there was a significantly increased higher risk of the primary outcome with therapy with an antiplatelet agent (HR = 1.31) or with no antithrombotic therapy (HR = 1.51). Compared with therapy with an OAC alone, there was a trend toward lower risk of the primary outcome in patients taking an OAC plus antiplatelet therapy (HR = 0.91 overall and HR = 0.79 in patients with —Fred Morady, MD, FACC coronary heart disease). “Combination OAC and antiplatelet therapy in patients at high cardiovascular risk requires evaluation in clinical trials, particularly with the newer OACs, given their more favorable risk-benefit ratio compared with warfarin,” the researchers said. In reviewing the study for Cardiosource.org, Fred Moraday, MD, said, “It is possible that an OAC was not prescribed in some of these patients because of a perceived high risk of bleeding complications. However, the primary outcome included major bleeds, and it is clear that the benefit of OACs outweighed their risk.” ■ McGrath ER, Kapral MK, Fang J, et al. Stroke. 2014;doi:10.1161/ STROKEAHA.114.006929. December 2014