Researchers adapted a simplified version of the SYNTAX anatomical risk score to readily available angiographic data from the VA Clinical Assessment, Reporting and Tracking Program, including coronary anatomical dominance, location of stenosis and coronary segment, ostial location, noted calcification or thrombus associated with the lesion and bifurcation status.

VA SYNTAX scores were calculated and categorized by tertiles of score across all patients who underwent revascularization. The primary outcome was a composite of death, revascularization, rehospitalization for myocardial infarction (MI) and rehospitalization for stroke after initial revascularization (major adverse cardiovascular and cerebrovascular events [MACCE]). Individual clinical events were assessed as secondary endpoints.

The VA SYNTAX score was computed automatically based on data provided by physicians interpreting each angiogram. A slight increase in the anatomical risk score occurred for patients who had PCI (9.5 in 2010 to 10.5 in 2017; p<0.001 for trend) and CABG (10.5 in 2010 to 11.0 in 2017; p=0.02 for trend) over time.

The researchers divided VA SYNTAX anatomical complexity scores into tertiles. In patients who had PCI, the largest proportion (46.2 percent) was in tertile 1 (scores ≤7) and the lowest proportion (18.2 percent) was in tertile 3 (scores ≥15). Most patients undergoing CABG had the most anatomically complex disease (60.6 percent), with a small proportion (10.0 percent) in tertile 1.

In PCI patients, increasing anatomical complexity was associated with an increased risk of MACCE. The adjusted hazard ratio (aHR) was significantly higher in tertiles 2 and 3 (1.44 and 2.13, respectively) vs. tertile 1. This relationship was not seen in CABG patients; only repeat revascularization was associated with increasing complexity (aHR, 1.34).

For external validation, the VA SYNTAX score was applied to patients in the EXCEL trial. Among PCI patients, the proportion of patients who experienced MACCE increased with increasing tertiles of scores; among CABG patients, there was a similar proportion of patients across tertiles.

"These findings suggest that a simplified anatomical risk model can be automatically calculated from registry data and may be useful in predicting longitudinal outcomes for patients undergoing revascularization, independent of clinical characteristics," the authors write.

Valle JA, Glorioso TJ, Bricker R, et al. JAMA Cardiol 2019;Jun 26:[Epub ahead of print].

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According to the results, among 6,471 STEMI patients with AFib or flutter, 15.7 percent were on warfarin, 13.0 percent were on DOACs and 71.3 percent were not taking an anticoagulant. Of 19,954 NSTEMI patients, 22.8 percent were on warfarin, 15.4 percent were on DOACs and 61.9 percent were not taking an anticoagulant.

Among STEMI patients, there were no significant differences in major bleeding based on anticoagulant status, with major bleeding occurring in 12.4 percent of those on warfarin, 11.2 percent on DOACs and 13.2 percent for no anticoagulant.

In addition, among STEMI patients undergoing primary PCI or receiving thrombolytic therapy, there were no differences in major bleeding based on anticoagulant status. STEMI patients had in-hospital mortality rates of 14.7 percent for those on warfarin, 10.8 percent on DOACs and 14.9 percent not on an anticoagulant.

For NSTEMI patients, in-hospital major bleeding rates were 7.0 percent among those on warfarin, 5.7 percent on DOACs and 6.7 percent for no anticoagulant. NSTEMI patients who received angiography or PCI within 48 hours were more likely to experience bleeding than those treated conservatively. Among NSTEMI patients, the in-hospital mortality rates were 5.5 percent for those on warfarin, 3.7 percent for DOACs and 6.1 percent for no anticoagulant.

According to the researchers, the study suggests that home use of warfarin or DOACs is not associated with increased bleeding among AMI patients with a prior history of AFib and may be associated with reduced mortality risk compared with no anticoagulant. They conclude that "in-hospital outcomes of STEMI and NSTEMI patients with AFib are not negatively affected by home warfarin or DOAC therapy despite the perceived high bleeding risk."

Feldman DN, Wang TY, Chen AY, et al. J Am Heart Assoc 2019;8(8):e011606.

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There were 18,117 patients included in the study and 2.2 percent developed perioperative AFib. Patients with perioperative AFib were older and more likely to have diabetes, congestive heart failure and a prior stroke or transient ischemic attack. The incidence of stroke was 5.58 per 100 patient-years (95 percent confidence interval [CI], 4.14-7.02) in patients with perioperative AFib vs. 1.54 per 100 patient-years (95 percent CI, 1.43-1.64) in patients without perioperative AFib.

An increased risk of stroke was seen in patients with perioperative AFib (hazard ratio [HR], 4.17; 95 percent CI, 2.47-7.06) that persisted after adjustment (adjusted HR, 3.43; 95 percent CI, 2.00-5.90). Patients with perioperative AFib were also at higher risk of all-cause mortality, vascular mortality and MI. As a sensitivity analysis, the authors excluded patients who were anticoagulated (n=1,117) at the time of randomization and found a similar increased risk of adverse events.

"Based on these data showing that patients with perioperative AFib are at high risk of adverse outcomes, there is an urgent need to evaluate whether they can be safely reduced using oral anticoagulation or other treatments in this patient population," the authors write.

Conen D, Alonso-Coello P, Douketis J, et al. Eur Heart J 2019;Jun 25:[Epub ahead of print].

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The short-term prognostic endpoint was the composite of subsequent MI (excluding index event) and 30-day mortality. Evaluation of diagnostic performance was performed in 9,604 patients and validated in 13,047 patients. The association between hs-Tn and long-term outcomes was examined in 7,682 matched pairs of participants (from the acute chest pain cohorts and 11 general population cohorts).

Of 22,651 patients, 3,455 (15.3 percent) presented with acute MI. The authors present the data by grouping patients according to negative predictive value/positive predictive value categories derived from combinations of hs-Tn cut-offs, absolute change in levels and resampling times (early 45-120 min vs. late 120-210 min). For example, hs-Tn <6 ng/L and an absolute change of <4 ng/L after 45-120 minutes resulted in a negative predictive value of 99.5 percent for MI.

In patients without acute MI, hs-Tn levels are strongly associated with a higher risk of long-term MI or death at one and two years.

"[I]n the COMPASS-MI project, we developed a tool that integrated the high-sensitivity troponin I or troponin T concentration at presentation, its dynamic change during serial sampling and the time between the obtaining of samples to allow for the estimation of both the probability of myocardial infarction on emergency department presentation and 30-day outcomes," the authors conclude. "We also provided estimates of long-term risk on the basis of the initial concentration of high-sensitivity troponin at presentation among patients in whom myocardial infarction was ruled out."

Neumann JT, Twerenbold R, Ojeda F, et al. N Engl J Med 2019;380:2529-40.

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Upper GI bleeding occurred in 471 patients during one-year of follow-up, or an annual incidence of 1.0 percent. Upper GI bleeding was seen in 1.7 percent of high-risk patients. Overall, compared with no therapy, PPI therapy was associated with a risk ratio for upper GI bleeding of 0.62 (95 percent confidence interval [CI], 0.48-0.77), corresponding to an absolute risk difference of 0.44 percent (95 percent CI, 0.39-0.48 percent). For high-risk patients, PPI therapy was associated with a similar absolute risk difference (0.47 percent; 95 percent CI, 0.43-0.51).

The authors state these findings suggest that bleeding prevention strategies should be better implemented in clinical practice, especially for those at higher risk for bleeding. PPI prescription increased throughout the study period but were still used less than recommended guidance for patients at increased risk for upper GI bleeding.

The researchers also found that while the guidelines' definition for high-risk correctly identified patients at higher risk of upper GI bleeding compared with the low-risk group, this risk stratification did not appear to identify patients with the most benefit of PPI therapy.

"Developing of future or improving established risk assessment schemes could potentially assist in identifying patients with greater treatment benefits," they conclude.

Sehested TS, Carlson N, Hansen PW, et al. Eur Heart J 2019;40:1963-70.

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