Patients with anemia present with high ischemia and bleed risk scores, complex coronary disease, and have adverse outcomes. Incomplete revascularization was associated with worse survival regardless of anemia status.
Although randomized trial data suggest that complete revascularization improves outcomes after percutaneous coronary intervention (PCI), the impact of differing revascularization strategies in octogenarians is not well defined. We performed a retrospective analysis, which was conducted of 9,628 consecutive patients who underwent PCI at a large UK center. Octogenarians were more likely to have significant co-morbidity, a higher Mehran bleed risk score (24.5 ± 6.8 vs 13.3 ± 7.4, p <0.0001), and more complex disease (baseline SYNTAX score 18.7 ± 11.0 vs 13.1 ± 8.9, p = 0.002) than younger patients. During PCI, octogenarians were more likely to undergo left main or proximal LAD intervention, but despite this, significantly less likely to receive drug-eluting stents (66.5% vs 80.1%, p <0.001). Postprocedurally, octogenarians had greater residual disease burden (residual SYNTAX score 10.1 ± 8.7 vs 1.6 ± 3.3, p <0.0001). At 12 months, adverse outcomes (definite stent thrombosis 3.3% vs 1.1%, p <0.001, clinically driven in-stent restenosis PCI 3.7% vs 2.6%, p = 0.005, and 12-month mortality 12.8% vs 4.2%, p <0.0001) were all more frequent in octogenarians. Although age, shock, diabetes, and BMS use were independently predictive of increased 12-month mortality, incomplete revascularization was not. In conclusion, octogenarians are a complex group to treat balancing high-risk bleeding profile and complex coronary disease. However, in multivariate analysis, incomplete revascularization was not independently predictive of adverse outcomes. These data support a conservative target lesion-only DES-driven revascularization strategy.
IntroductionProlonged dual anti-platelet therapy (DAPT) may cause excess bleeding in certain patients. The biolimus-A9 drug-coated stent (BA9-DCS) has a rapid drug-elution profile allowing shortened DAPT. Data were gathered on the early experience implanting this stent in drug-eluting stent eligible patients deemed to be at high risk of bleeding.Background and MethodsThe demographics, procedural data and clinical outcomes were gathered prospectively for 249 patients treated with a BA9-DCS stent at 2 UK centres, and compared to a cohort of patients treated in the same period with drug-eluting stents (PCI-DES).ResultsOperator-defined BA9-DCS indications included warfarin therapy, age, and anaemia. Patients receiving a BA9-DCS were older (71.6±11.8 vs. 64.8±11.6yrs, p<0.001), more often female (38.2 vs. 26.8%, P<0.001), and more likely to have comorbidity including chronic kidney disease or poor LV function than PCI-DES patients. The baseline Mehran bleed risk score was also significantly higher in the BA9-DCS group (19.4±8.7 vs. 13.1±5.8, p<0.001). Of the BA9-DCS cohort, 95.5% of patients demonstrated disease fitting NICE criteria for DES placement. The number of lesions treated (1.81±1.1 vs. 1.58±0.92, p = 0.003), total lesion length (32.1±21.7 vs. 26.1±17.6mm, p<0.001), number of stents used (1.93±1.11 vs. 1.65±1.4, p = 0.007) and total stent length (37.5±20.8 vs. 32.4±20.3, p<0.01) were greater for BA9-DCS patients. DAPT was prescribed for 3.3±3.9 months for BA9-DCS patients and 11.3±2.4 months for PCI-DES patients (p<0.001). At follow up of 392±124 days despite the abbreviated DAPT course stent related event were infrequent with ischemia-driven restenosis PCI (2.8 vs. 3.4%, p = 0.838), and stent thrombosis (1.6 vs. 2.1%, p = 0.265) rates similar between the BA9-DCS ad PCI-DES groups. After propensity scoring all clinical end-points were similar between both cohorts.ConclusionsThis early experience using polymer-free BA9 drug-coated stents in drug-eluting stent type patients at risk of bleeding are encouraging. Further studies are warranted.
Introduction: Prolonged dual anti-platelet therapy (DAPT) is undesirable in certain patients. The biolimus-A9 drug-coated stent (BA9-DCS) has a rapid drug-elution profile allowing shortened DAPT.Methods: The demographics, procedural data, and clinical outcomes for 505 patients presenting with an ACS to three UK centres and treated with a BA9-DCS stent (PCI-DCS) were collected, and compared to a consecutive ACS cohort of unselected patients treated in the same period with drug-eluting stents (PCI-DES).Results: PCI-DCS patients were older, more often female with hypertension, chronic kidney disease, severe LV dysfunction, and peripheral vascular disease more frequent than the PCI-DES cohort. PCI-DCS patients had a much higher Mehran bleed risk score (21.5 AE 7.7 vs. 15.9 AE 7.7, P < 0.0001). Baseline disease burden was greater in the PCI-DCS cohort with more left main and three vessel disease. During PCI, more stents (1.91 AE 1.1 vs. 1.57 AE 0.94, P < 0.0001), total stent length (38.2 AE 20.8 vs. 31.4 AE 20.3, P < 0.0001) and longer stents (38.2 AE 20.8 vs. 31.4 AE 20.3 mm, P < 0.0001) were used in the PCI-DCS cohort with rotational atherectomy also used more frequently. Physician-recommended DAPT duration was 2.9 AE 3.9 months for PCI-DCS patients and 11.3 AE 2.4 months for PCI-DES patients (P < 0.0001). At 12-month follow-up, definite stent thrombosis (0.6% vs. 1.1%) and TLR (3.2% vs. 2.7%) rates were similar between the two groups.After adjustment for baseline differences, there were no statistically significant differences in death and combined MACE rates at 12 months. Conclusions:The outcomes of patients treated with polymer-free BA9 drug-coated stent who present with an ACS and who were deemed unsuitable for prolonged DAPT are encouraging.Further studies are warranted. K E Y W O R D Sbiolimus A9 drug-coated stent, DAPT duration, high-bleeding risk
IntroductionElderly patients (≥80years) represent an increasingly large sub-group of patients undergoing percutaneous coronary intervention (PCI). However their characteristics and outcomes are not well defined.MethodsA retrospective analysis was conducted of all patients who underwent PCI at a large UK cardiac centre between 2008 and 2014.Results9,628 patients underwent PCI with the mean age increasing from 62.4 ± 11.4yrs in 2008 to 64.8 ± 11.8yrs in 2014. Elderly patients were more likely to be female, have severe LV dysfunction, and more likely to have significant comorbidity than younger patients. Elderly patients had a higher Mehran bleed risk score (24.5 ± 6.8 vs. 13.3 ± 7.4, p < 0.0001), more complex disease with higher baseline SYNTAX score (18.7 ± 11.0 vs. 13.1 ± 8.9, p = 0.002), a greater incidence of left main or proximal LAD disease, and more vessels diseased. During PCI the elderly were more likely to undergo left main or proximal LAD intervention but significantly less likely to receive a BMS (34.5 vs. 19.9%, p < 0.001). The elderly cohort had greater residual disease burden (residual SYNTAX 10.1 ± 8.7 vs. 1.6 ± 3.3, p < 0.0001) and a greater likelihood of adverse outcomes (definite stent thrombosis 2.1 vs. 3.3%, p = 0.017, clinically driven ISRS-PCI 3.7 vs. 2.6%, p = 0.036, and mortality 12.8 vs. 4.2%, p < 0.0001) at 12-months.ConclusionsElderly patients represent an increasingly large cohort of patients requiring PCI, have increased comorbidity and complex coronary disease, and are more likely to receive incomplete revascularisation, BMS and have adverse 12-month outcomes.
BackgroundProlonged DAPT is undesirable in some patients. A biolimus-A9 drug-coated stent (BA9-DCS) has a rapid drug-elution profile potentially allowing shortened DAPT.MethodsData were gathered prospectively for 410 patients deemed to be at high risk of bleeding treated with a BA9-DCS stent at 2 UK centres and compared to usual PCI patients.ResultsBA9-DCS indications included warfarin therapy, age and anaemia. Patients receiving a BA9-DCS were older (71.6 ± 11.8 vs. 64.8 ± 11.6yrs, p < 0.001), more often female (38.2 vs. 26.8%, P < 0.001) and to have comorbidity including hypertension, chronic kidney disease or poor LV function than usual PCI patients. The baseline Mehran bleed risk score was also significantly higher in the BA9-DCS group (19.4 ± 8.7 vs. 13.1 ± 5.8, p < 0.001). Of the BA9-DCS cohort, 95.5% of patients demonstrated disease fitting NICE criteria for DES eligibility. The number of lesions treated (1.81 ± 1.1 vs. 1.58 ± 0.92, p = 0.003), total lesion length (32.1 ± 21.7 vs. 26.1 ± 17.6mm, p < 0.001), number of stents used (1.93 ± 1.11 vs. 1.65 ± 1.4, p-0.007) and total stent length (37.5 ± 20.8 vs. 32.4 ± 20.3, p < 0.01) were greater for BA9-DCS patients. DAPT was prescribed for 3.3 ± 3.9 months for BA9-DCS patients and 11.3 ± 2.4 months for usual PCI patients (p < 0.001). At follow up of 392 ± 124 days event rates were low with ischemia-driven restenosis PCI occurring in 6 patients (2.4%), definite/probable stent thrombosis in 2 patients (0.8%) and death in 13 patients (5.2%).ConclusionsEarly outcomes using polymer-free BA9 drug-coated stents are encouraging. Further studies are warranted.
IntroductionPatients treated with warfarin who undergo percutaneous coronary intervention (PCI) present a difficult therapeutic problem. Their baseline demographics, procedural characteristics and 12-month outcomes are poorly defined.MethodsWe conducted a retrospective analysis of all patients who underwent PCI at a major UK cardiac centre between 2012 and 2013. Of the 2675 patients who underwent PCI, 155 were on long-term warfarin (5.8%). Patients on warfarin were older and more likely to have significant comorbidity than patients not on warfarin.ResultsThe Mehran bleed scores (19.0 ± 5.8 vs. 15.4 ± 8.0, p = 0.004) and baseline SYNTAX scores (18.5 ± 9.1 vs. 12.4 ± 3.8, p = 0.0006) were higher in patients treated with warfarin vs. those not treated. Bare metal stents were more frequently utilised in warfarin patients than non-warfarin patients (44.8 vs. 26.3%, p < 0.0001) and residual SYNTAX scores were higher (8.3 ± 1.1 vs. 3.8 ± 5.9, p = 0.001). Anti-platelet mono-therapy was prescribed after PCI in 14.4% of warfarin patients and 0.7% of non-warfarin (p < 0.0001) whilst mean DAPT duration was also significantly shorter (4.3 vs. 10.7 months, p < 0.0001). At 1-year follow-up TVR (6.5 vs. 3.3%, p < 0.05), stent thrombosis (5.0 vs. 2.6%, p = 0.14), death (10.1 vs. 4.6%, p < 0.01) and TVR/ST/death (21.6% vs. 10.5%, p = 0.004) were all more common in the warfarin cohort.ConclusionIn conclusion patients treated with warfarin who undergo PCI are a complex cohort and are more likely to receive incomplete revascularisation, less intense and shorter durations of anti-platelet therapy and have adverse 1-year outcomes.
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