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