Impact of anemia as risk factor for major bleeding and mortality in patients with acute coronary syndrome

Vicente‐Ibarra, Nuria; Marı́n, Francisco; Pernias-Escrig, V; Sandín‐Rollán, Miriam; Núñez-Martínez, Laura; Lozano, Teresa; Macías-Villaniego, Manuel Jesús; Carrillo-Aleman, L; Candela-Sanchez, E; Guzmán, Elena Gómez; Esteve-Pastor, María Asunción; Orenes‐Piñero, Esteban; Valdés, Mariano; Rivera‐Caravaca, José Miguel; Ruiz-Nodar, Juan M.

doi:10.1016/j.ejim.2018.12.004

Cited by 20 publications

(10 citation statements)

References 21 publications

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“…In fact, in the RENAMI registry (registry of new antiplatelet therapy in patients with acute myocardial infarction), 16 including 4,424 ACS patients treated with prasugrel or ticagrelor at hospital discharge, anemia was independently associated with mortality and bleedings, with no impact on stent thrombosis or reinfarction. Similar results were reported in a Spanish registry 34 enclosing a “real world” population of ACS patients, where anemia could predict the risk of mortality and bleedings, but not of MACE, and, in addition, long‐term mortality was higher in anemic patients taking clopidogrel rather that the newer antiplatelet drugs.…”

Section: Discussionsupporting

confidence: 84%

Low hemoglobin predicts high‐platelet reactivity and major cardiovascular ischemic events at long‐term follow‐up among ACS patients receiving dual antiplatelet therapy with ticagrelor

Verdoia

Rolla

Pergolini

et al. 2021

Cathet Cardio Intervent

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Background Reduced levels of hemoglobin (Hb) represent an established marker of impaired outcomes and increased cardiovascular risk in patients with coronary artery disease, challenging the management of dual antiplatelet therapy (DAPT). However, while anemia has emerged as an independent predictor of suboptimal platelet inhibition in patients receiving clopidogrel, no study has so far evaluated the impact of Hb levels on high‐on treatment platelet reactivity (HRPR) with ticagrelor and their prognostic consequences, that were the aim of the present study. Methods Patients on DAPT with ASA + Ticagrelor (90 mg/twice a day) after percutaneous coronary revascularization for ACS were scheduled for platelet function assessment 30–90 days post‐discharge. Aggregation tests were performed by multiple electrode aggregometry. Suboptimal platelet inhibition (HRPR‐high residual platelet reactivity was defined if above the lower limit of normality (417 AU*min). The primary study endpoint was defined as the occurrence of major cardiovascular events (a composite of cardiovascular death, recurrent acute coronary syndrome [MI], target vessel revascularization) at longest available follow‐up. Results We included 397 patients that were divided according to tertiles values of Hb (< 12.7, 12–7–14.09, ≥14.1 g/dl). Patients with lower Hb were older and displayed a more severe cardiovascular risk profile. Mean levels of platelet reactivity were enhanced in patients with lower Hb after stimulation with TRAP peptide (TRAP test, p = .03) and ADP (p = .02). Elevated platelet reactivity (HRPR) on Ticagrelor was more frequent among patients with reduced Hb (16.4% vs. 12% vs. 5.4%, p = .005, adjusted OR [95%CI] = 1.71[0.996;3.01], p = .056). At a mean follow‐up of 820.9 ± 553.4 days, 21.4% of the patients experienced the primary composite endpoint, with a higher rate of events in patients with lower Hb (27.6% vs. 22.6% vs. 13.5%, p = .006, adjusted HR [95%CI] = 1.51[1.12; 2.03], p = .006), mainly driven by a higher rate of recurrent ACS. After correction for baseline differences lower Hb tertiles but not HRPR emerged as independent predictor of MACE (adjusted HR [95%CI] = 0.98[0.50; 1.92], p = .95). Conclusions In the present study, we demonstrated that among patients on DAPT with ASA and ticagrelor after PCI for ACS, lower Hb levels are independently associated with a higher rate of HRPR and an increased rate of major ischemic events, and especially for recurrent ACS, although with no impact on survival. Neutral prognostic effect of HRPR was observed across Hb tertiles.

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Section: Discussionsupporting

confidence: 84%

Low hemoglobin predicts high‐platelet reactivity and major cardiovascular ischemic events at long‐term follow‐up among ACS patients receiving dual antiplatelet therapy with ticagrelor

Verdoia

Rolla

Pergolini

et al. 2021

Cathet Cardio Intervent

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“…In most published series on MINOCA, patients with an ACS but without significant lesions have been younger and more likely to be women than patients with obstructive lesions [ 21 , 22 ]. Our sample confirms this tendency, with a younger mean age, a greater proportion of women, and a lower prevalence of risk factors (particularly diabetes) compared to ACS registries in the same population [ 23 – 25 ].…”

Section: Discussionsupporting

confidence: 79%

Role of cardiovascular magnetic resonance in the prognosis of patients with myocardial infarction with non-obstructive coronary arteries

Vicente‐Ibarra

Feliu

Bertomeu‐Martínez

et al. 2021

Journal of Cardiovascular Magnetic Resonance

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Background It is estimated that 5% to 10% of patients with myocardial infarction (MI) present with no obstructive coronary artery lesions. Until now, most studies have focused on acute coronary syndrome, including different clinical entities with a similar presentation encompassed under the term MINOCA (MI with non-obstructive coronary arteries). The aim of this study is to assess the prognosis of patients diagnosed with true infarction, confirmed by cardiovascular magnetic resonance (CMR), in the absence of significant coronary lesions. Methods Prospective multicenter registry study, including 120 consecutive patients with a CMR-confirmed MI without obstructive coronary artery lesions. The primary clinical outcome was major adverse cardiovascular events (MACE: death, non-fatal infarction, stroke, or cardiac readmission), assessed over three years. Results Seventy-six patients (63.3%) were admitted with a diagnosis of acute coronary syndrome, and 44 (36.6%) for other causes (mainly heart failure); the definitive diagnosis was established by CMR. Most patients (64.2%) were men, and the mean age was 58.8 ± 13.5 years. Patients presented with small infarcts: 83 (69.1%) showed late gadolinium enhancement (LGE) in one or two myocardial segments, mainly transmural (in 77.5% of patients) and with a preserved left ventricular ejection fraction (median 54.8%, interquartile range 37–62). The most frequent infarct location was inferolateral (n = 38, 31.7%). During follow-up, 43 patients (35.8%) experienced a MACE, including 9 (7.5%) who died. In multivariable analysis, LGE in two versus one myocardial segment doubled the risk of adverse cardiac events (hazard ratio [HR] 2.32, 95% confidence interval [CI] 0.97–5.83, p = 0.058). Involvement of three or more myocardial segments almost tripled the risk (HR 2.71, 95% CI 1.04–7.04, p = 0.040 respectively). Conclusions Patients with true MI but without significant coronary artery lesions predominantly had small infarcts. Myocardial 3-segment LGE involvement is associated with a significantly higher risk of adverse cardiac events.

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“…Thus, the increased bleeding risk of a low eGFR might not be explained only by uremic thrombocytopathy but partially also by a higher percentage of aspirin use in these patients. Low hemoglobin has been previously associated with an increased risk of major bleeding [13][14][15][16][17][18][19], possibly because transfusion and intervention thresholds are reached even after moderate bleeding in patients with low baseline hemoglobin. However, even when excluding blood transfusion as a component from major bleeding, we still found more relevant bleeding episodes in patients with low hemoglobin levels.…”

Section: Discussionmentioning

confidence: 99%

Safety of Kidney Biopsy when Performed as an Outpatient Procedure

Bonani

Seeger

Weber

et al. 2021

Kidney Blood Press Res

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Introduction: Kidney biopsy remains the gold standard for the diagnosis of most renal diseases. A major obstacle to performing a biopsy is safety concerns. However, many safety measures are not evidence based and therefore vary widely between centers. We sought to determine the rate and timing of kidney biopsy complications in our center, to compare the complication rate between native and transplant kidney biopsies, to evaluate the feasibility of performing kidney biopsies as an outpatient procedure and the value of a postbiopsy ultrasound before discharge, and to identify risk factors for complications. Methods: We performed a single-center, retrospective, observational study at the Division of Nephrology of the University Hospital Zurich including all patients who underwent renal biopsy between January 2005 and December 2017. Major bleeding (primary outcome) and any other bleeding or nonbleeding complications (secondary outcomes) were compared between native and transplant kidney biopsies and between inpatient and outpatient procedures and correlated with clinical factors possibly affecting bleeding risk. Results: Overall, 2,239 biopsies were performed in 1,468 patients, 732 as inpatient and 1,507 as outpatient procedures. Major bleeding was observed in 28 (3.8%) inpatient and in 15 (1.0%) outpatient procedures, totaling to 43 (1.9%) of all biopsies. Major bleeding requiring intervention amounted to 1.0% (0.5% of outpatient procedures). Rate of major bleeding was similar between native and transplant kidneys. 13/15 (87%) bleeding episodes in planned outpatient procedures were detected during the 4-h surveillance period. Risk factors for bleeding were aspirin use, low eGFR, anemia, cirrhosis, and amyloidosis. Routine postbiopsy ultrasound did not change management. Conclusions: Kidney biopsy is an overall safe procedure and can be performed as an outpatient procedure in most patients with an observation period as short as 4 h. The value of routine postbiopsy ultrasound is questionable.

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Impact of anemia as risk factor for major bleeding and mortality in patients with acute coronary syndrome

Cited by 20 publications

References 21 publications

Low hemoglobin predicts high‐platelet reactivity and major cardiovascular ischemic events at long‐term follow‐up among ACS patients receiving dual antiplatelet therapy with ticagrelor

Low hemoglobin predicts high‐platelet reactivity and major cardiovascular ischemic events at long‐term follow‐up among ACS patients receiving dual antiplatelet therapy with ticagrelor

Role of cardiovascular magnetic resonance in the prognosis of patients with myocardial infarction with non-obstructive coronary arteries

Safety of Kidney Biopsy when Performed as an Outpatient Procedure

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