April 22, 2019
By Marilynn Larkin
NEW YORK (Reuters Health) - In anemic patients who have undergone percutaneous coronary intervention (PCI), non-adherence to dual antiplatelet therapy (DAPT) - but not physician-recommended discontinuation - is associated with a higher risk of major adverse cardiovascular events (MACE) in the two years following the procedure, researchers say.
The study "underlines the importance of anemia as a consideration in the decision making for DAPT duration, adherence, and choices," Dr. Roxana Mehran of the Icahn School of Medicine at Mount Sinai in New York City told Reuters Health by email. "Anemia is obviously linked to bleeding, as anemic patients with acute blood loss during and around the time of PCI may require more aggressive intervention and treatment. Anemic patients were also at risk for important ischemic complications, such as myocardial infarction."
"We found that anemic patients were more likely to have their antiplatelet regimen interrupted or disrupted compared to non-anemic patients," she added. "Physician-guided discontinuation and interruption were NOT associated with increased MACE, but disruption of DAPT (non-compliance or due to bleeding) was associated with higher MACE."
Dr. Mehran and colleagues studied 5,018 patients who underwent PCI, of whom 824 (18%) were anemic at baseline. Anemia was defined as baseline Hb (hemoglobin) <12 g/dL for men and <11 g/dL for women.
DAPT cessation modes included physician-recommended discontinuation, temporary interruption (up to two weeks), and disruption due to bleeding or nonadherence.
As reported online April 15 in the Journal of Hepatology, 33% of anemic and 24% of nonanemic patients were women. Anemic patients were older (mean age, 68 versus 62) and had more diabetes (51% vs. 30%), hypertension (90% vs. 76%), and prior PCI (40% vs. 36%).
At 30 days after PCI, the rate of DAPT cessation was 6.8% in patients treated with bare metal stents, 2.2% in those treated with first-generation drug-eluting stents (DES), and 1.9% in patients treated with second-generation DES. At two years, the cessation rates were 66.6%, 48.6%, and 51.8%, respectively.
DAPT interruption and disruption were significantly more common in anemic patients throughout two years after PCI. However, physician-recommended discontinuation occurred more often in anemic patients during the first year after PCI and in nonanemic patients during the second year.
Risks of MACE and Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding events were significantly higher in anemic patients at both one and two years. Specifically, MACE occurred in 10.2% of anemic versus 6.9% of nonanemic patients at one year and in 17.8% versus 10.4% at two years. Rate for BARC 3 or 5 bleeding were 7.5% versus 1.7% at one year and 10% versus 2.8% at two years.
Compared with uninterrupted DAPT, disruption, but not interruption and physician-recommended discontinuation, was associated with a higher risk of myocardial infarction in nonanemic patients and a higher risk of both myocardial infarction and MACE in anemic patients. However, baseline anemia did not modify the risk of clinical outcomes associated with any DAPT cessation modality.
"Anemic patients should be educated on the importance of their DAPT early after stenting," Dr. Mehran said. "Also, there needs to be an evaluation for anemic patients who should be receiving a shorter duration of DAPT."
Dr. Craig A. Thompson, director of interventional cardiology at NYU Langone Health, told Reuters Health he agrees with the findings, "and this observation is consistent with our clinical practice. Anemia does tend to be associated with other health challenges we see in our patients and collectively this group is at higher risk for coronary interventional procedures."
However," he said by email, "our newer generation coronary stents heal well and offer the opportunity to more safely stop these medications sooner for selected patients."
The PARIS registry was sponsored and funded by Bristol-Myers Squibb and Sanofi-Aventis. Dr. Mehran and six coauthors have received funds from these companies and others.
Circ Cardiovasc Interv 2019.
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