Prognostic value of GRACE and CHA2DS2-VASc score among patients with atrial fibrillation undergoing percutaneous coronary intervention

AimsThe GRACE and CHA2DS2-VASc risk score are developed for risk stratification in patients with acute coronary syndrome and AF, respectively. We aimed to assess the predictive performance of the GRACE score and CHA2DS2-VASc score among patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).MethodsConsecutive patients with a diagnosis of AF admitted to our hospital for PCI between January 2016 and December 2018 were included and followed up for at least 1 year. The primary endpoint was a composite of major adverse cardiac events (MACEs) including all-cause mortality, repeat revascularization, myocardial infarction, or ischaemic stroke.ResultsA total of 1452 patients were identified. Cox regression demonstrated that the GRACE (HR 1.014, 95% CI 1.008–1.020, p < 0.001) but not the CHA2DS2-VASc score was associated with the risk of MACEs. Both GRACE and CHA2DS2-VASc scores were predictive of all-cause mortality with HR of 1.028 (95% CI 1.020–1.037, p < 0.001) and 1.334 (95% CI 1.107–1.632, p = 0.003). Receiver operating characteristic analyses showed both scores had similar discrimination capacity for all-cause mortality (C-statistic: 0.708 for GRACE vs. 0.661 for CHA2DS2-VASc, p = 0.299). High GRACE score was also significantly associated with increased risk of ischaemic stroke (HR 1.018, 95% CI 1.005–1.031, p = 0.006) and major bleeding (HR 1.012, 95% CI 1.001–1.024, p = 0.039), whereas high CHA2DS2-VASc score was not.ConclusionsHigh GRACE score but not CHA2DS2-VASc score were both associated with an increased risk of MACEs after PCI in patients with AF. The GRACE and CHA2DS2-VASc scores have similar predictive performance for predicting all-cause mortality.

Key messages:

• In patients with AF undergoing PCI, increasing GRACE but not CHA2DS2-VASc scores was independently associated high risk of MACEs.
• The GRACE score could also help identify patients at higher risk of stroke and major bleeding.
• Both GRACE and CHA2DS2-VASc scores showed good ability in the prediction of all-cause mortality.

     

Prognosis of patients with atrial fibrillation undergoing percutaneous coronary intervention receiving drug eluting stents

Background

Atrial fibrillation (AF) is increasingly prevalent in elderly patients and adversely affects clinical outcomes after coronary artery bypass grafting, non-cardiac surgery or myocardial infarction. Aim of the present analysis was to investigate the prognostic impact of AF in patients undergoing drug eluting stent (DES) implantation during a 1-year follow-up.

Patients and methods

5,772 consecutive patients undergoing percutaneous coronary intervention were enrolled into the German Drug Eluting Stent Registry (DES.DE) and were followed for 12 months. Of these 455 had AF and 5,317 in sinus rhythm served as controls. Univariate and multivariate logistic regression analyses were used to determine the risk of major adverse cardiac and cerebrovascular events (MACCE) and bleeding complications.

Results

Patients with AF were older (71.3 ± 7.6 vs. 64.7 ± 10.5 years) and had a higher prevalence of diabetes, hypertension, renal insufficiency as well as more prior bypass surgery, stroke and peripheral arterial disease. Cardiogenic shock (2.9 vs. 1.4 %; p < 0.05), left ventricular ejection fraction ≤40 % (21.0 vs. 11.4 %; p < 0.0001) and triple vessel disease (44.4 vs. 37.9 %; p < 0.01) were more frequent in patients with AF than in controls. MACCE (OR 2.08, 95 % CI 1.56–2.77), total mortality (OR 3.27, 95 % CI 2.32–4.62) and non-fatal stroke (OR 2.03, 95 % CI 1.03–4.00) as well as bleeding complications (OR 1.88, 95 % CI 1.13–3.12) during the 1-year follow-up were more frequent in patients with AF (univariate analysis). In multivariate analyses adjusting for covariates determined to be relevant at baseline, the risk for total mortality remained elevated (OR 1.63, 95 % CI 1.05–2.52).

Conclusions

AF is an important predictor of long-term mortality in patients undergoing DES implantation.     

Performance and validation of a simplified postoperative atrial fibrillation risk score

Background

Postoperative atrial fibrillation (POAF) occurs in 20–40% patients who received isolated coronary artery cardiac bypass surgery (CABG). Several POAF risk prediction models have been developed, but none of them is widely adopted in practice. Our objective was to derive and validate a simple scoring system to estimate POAF risk after isolated CABG, using easily available clinical information.

Methods

Medical records of 1,000 consecutive patients undergoing isolated CABG were reviewed. The data of first 700 patients were used for model derivation and data of the remaining 300 patients were used for model validation. Discrimination and calibration of the newly developed model were assessed.

Results

POAF incidence in both the derivation and validation cohorts was 27.3%. Age ≥65, history of hypertension, heart failure, and myocardial infarction were independently associated with POAF risk. Risk scores were calculated by summing weighting points for each independent predictor. The score ≥3 was associated with high POAF incidence (41.1% in the derivation cohort and 44.3% in the validation cohort). The positive and negative POAF predictive value was 41.1% and 78.5%, respectively, in the derivation cohort, and 44.3% and 80.8%, respectively, in the validation cohort, when the cut‐point score ≥3 was used. The Hosmer–Lemeshow goodness‐of‐fit test P‐values were 0.917 and 0.894 in the derivation cohort and validation cohort, respectively.

Conclusions

This POAF risk following isolated CABG can be predicted with simple patient characteristic during the preoperative period. Patients with high risk scores (≥3) may constitute a target population for POAF prevention and prolonged postoperative surveillance.

     

脉压水平与经皮冠状动脉介入术患者的危险分层及预后评价

目的:通过对接受经皮冠状动脉介入治疗患者的临床特征,围手术期并发症和远期的疗效分析,了解脉压水平与经皮冠状动脉介入术患者的危险分层和预后关系。方法:选择2003-10/2005-10就诊于解放军第三○五医院心脏介入中心符合冠心病诊断标准并接受经皮冠状动脉介入治疗的631例患者。外周肱动脉压力测定收缩压、舒张压,脉压水平通过收缩压与舒张压差表示,冠状动脉病变的严重程度用冠脉病变积分表示。采用横断面前瞻性多变量观察研究,根据脉压>65mm Hg(1mm Hg=0.133kPa)和≤65mm Hg进行分组,其中脉压>65mm Hg组154例,男110例,女44例;脉压≤65mm Hg组477例,男288例,女189例。观察患者临床特征,随访[随访时间(18.6±4.3)个月]主要心血管事件发生率。结果:631例患者均进入结果分析。①与脉压≤65mm Hg组比较,脉压>65mmHg组年龄偏大,男性多见,高血压病史和糖尿病史多,C型病变和三支病变常见,冠脉病变积分高。②脉压>65mmHg组围手术期并发症发生率、住院期非致死性心肌梗死发生率和远期心源性死亡发生率显著高于脉压≤65mmHg组(16.8%,8.8%;5.2%,2.3%;1.3%,0.8%,P均<0.05)。③多因素logistic分析冠脉病变严重程度与脉压、年龄、糖尿病有正相关,OR分别为1.181(95%CI1.120～1.321),1.012(95%CI1.009～1.213),1.273(95%CI1.042～1.359)。结论:脉压与冠状动脉病变的严重程度密切相关,与经皮冠状动脉介入术围手术期及远期不良心血管事件发生率增加密切相关,可作为全身心血管疾病的一个危险信号,指导早期干预。     

P波离散度与TIMI危险评分对STEMI患者新发房颤的预测价值

目的探讨P波离散度(Pd)联合心肌梗死溶栓(TIMI)危险评分对急性ST段抬高型心肌梗死(STEMI)患者心房颤动(房颤)的预测价值。方法收集2011年3月至2014年9月在泰安市中心医院住院确诊为STEMI患者785例,根据住院7 d内是否发生房颤分为房颤组(98例)和非房颤组(687例)。采用Logistic回归及受试者工作特征(ROC)曲线分析Pd和TIMI危险评分与STEMI患者早期新发房颤的关系。结果发生房颤患者Pd与TIMI危险评分较未发生房颤患者明显升高[Pd:(45±13)ms vs.(33±10)ms,P<0.001 TIMI危险评分:8±4 vs.5±3,P<0.001]。多因素Logistic回归显示Pd与TIMI危险评分均可以独立预测STEMI患者住院7 d内房颤的发生。TIMI危险评分判定发生房颤的ROC曲线下面积要高于Pd(0.747 vs.0.708,P=0.023),将二者联合的ROC曲线下面积为0.791,均高于各自的预测值(P均<0.05)。根据ROC所计算Pd及TIMI危险评分的切点将患者分组,Pd及TIMI危险评分均增高的STEMI患者早期发生房颤的风险最大。结论临床联合应用Pd与TIMI危险评分可以预测STEMI患者新发房颤的发生。     

Metabolic syndrome and risk of restenosis in patients undergoing percutaneous coronary intervention

OBJECTIVE: Patients with metabolic syndrome have increased risk of cardiovascular events. The number of patients with metabolic syndrome is rapidly increasing, and these patients often need revascularization. However, only limited data are available on the effect of metabolic syndrome on restenosis in patients undergoing percutaneous coronary intervention (PCI). RESEARCH DESIGN AND METHODS: To assess the role of metabolic syndrome in the development of restenosis, we performed an analysis in a population of patients from the GENetic DEterminants of Restenosis (GENDER) study. The GENDER project, a multicenter prospective study, included consecutive patients after successful PCI and was designed to study the predictive value of various genetic and other risk factors for subsequent clinical restenosis, defined as target vessel revascularization (TVR) or combined end point of death, myocardial infarction, and TVR. This subpopulation of GENDER consisted of 901 patients, 448 of whom (49.7%) had metabolic syndrome. RESULTS: On multivariable Cox regression analysis, controlling for age, sex, previous myocardial infarction, stent length, current smoking, and statin therapy, there was no association between increased risk of TVR (hazard ratio 1.03 [95% CI 0.68-1.57]) or the combined end point (1.05 [0.71-1.55]) and the presence of metabolic syndrome. CONCLUSIONS: This study demonstrates that metabolic syndrome is not associated with TVR or the combined end point after PCI. Furthermore, accumulating characteristics of metabolic syndrome were neither associated with increased risk of TVR nor with the combined end point. Therefore, PCI has equal beneficial results in patients with or without metabolic syndrome. This is important information in light of the pandemic proportion of metabolic syndrome that the medical community will face.     

Contrast medium induced nephropathy in patients undergoing percutaneous coronary intervention for acute coronary syndrome: differences in STEMI and NSTEMI

Abstract  

The aim of this study was to assess the incidence, clinical predictors, and outcome of patients developing contrast medium induced nephropathy (CIN) after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS).     

Development and validation of a Chinese‐language instrument measuring empowerment needs of patients after a percutaneous coronary intervention

Patient empowerment has been shown to have some positive impacts on self‐efficacy, self‐esteem, and recovery. However, information about the empowerment needs of patients after a percutaneous coronary intervention is scarce. The aim of this study was to develop a Chinese‐language instrument to measure empowerment needs of such patients. The initial instrument was generated based on a literature review and interviews with patients after a percutaneous coronary intervention procedure. Content validity was tested with a panel of experts using the Delphi method. In total, 226 patients were recruited for psychometric tests using the revised instrument. Expert authority coefficient was 0.92, and content validity index was 0.95. The internal consistency reliability was demonstrated by Cronbach's α coefficients (0.86 for the total score, 0.66–0.74 for the dimensions). The newly developed 19‐item, five‐dimension instrument has shown satisfactory validity (face/content validity and construct validity) and internal consistency reliability. The instrument could help clinical nurses who have close contact with patients after a percutaneous coronary intervention to gain a better understanding of their empowerment needs and could help develop appropriate health education to address such needs.     

血管性血友病因子评估经皮冠状动脉介入术后新发心房颤动患者的卒中风险

目的观察血浆血管性血友病因子抗原(v WF:Ag)评估择期经皮冠状动脉介入治疗(PCI)后新发心房颤动(简称房颤)患者的卒中风险。方法选择天津医科大学总医院2016年2月至2017年2月PCI后新发非瓣膜性心房纤维性颤动患者127例(PCI后新发房颤组)、初入院尚未接受PCI的ACS患者50例(ACS对照组)、PCI后未发生房颤的ACS患者50例(PCI对照组)、体检健康者50例(健康人对照组)进行回顾性队列分析。检测上述研究对象血浆v WF:Ag,用ROC曲线评价v WF:Ag预测PCI后新发房颤患者发生卒中风险的性能。用χ2检验评估PCI后新发房颤患者v WF:Ag与临床病理因素的关联。用Kaplan-Meier曲线进行生存分析。结果健康人对照组血浆v WF:Ag测定结果为104.5%(88.0%,133.7%),ACS对照组161.7%(120.7%,270.5%),PCI对照组208.0%(125.2%,360.7%),PCI后新发房颤组284.9%(172.4%,494.2%);其中,PCI对照组高于ACS对照组(U=526.0,P0.01);PCI后新发房颤组高于PCI对照组(U=824.0,P0.01)。血浆v WF:Ag水平预测PCI后新发房颤患者发生卒中风险的ROC曲线下面积为0.882(95%CI:0.811~0.854),v WF:Ag医学决定水平设定为312.0%时,预测PCI后新发房颤患者发生卒中风险的敏感性为94.4%,特异性为60.6%。与低于312.0%的PCI后新发房颤患者比较,高于312.0%的患者在90 d随访期内的卒中累积概率增高(Log-rankχ2=44.308,P0.01)。PCI后新发房颤患者血浆v WF:Ag水平与慢性心力衰竭/左室功能障碍、高血压、年龄、卒中/短暂性脑缺血发作/血栓栓塞病史和血管疾病有关联(P0.01)。接受双联抗栓治疗患者的血浆v WF:Ag水平和卒中事件发生率高于接受三联抗栓治疗的患者(U=1 075.5,P0.01;χ2=10.45,P0.01)。结论血浆v WF:Ag水平能敏感地反映PCI后新发房颤患者的血管内皮细胞损伤状态、卒中风险以及抗凝药物治疗效果。     

Development and validation of clinical risk score to predict the cardiac rupture in patients with STEMI

Background

Cardiac rupture (CR) is a fatal complication of ST-elevation myocardial infarction (STEMI) with poor prognosis. The aim of this study was to develop and validate practical risk score to predict the CR after STEMI.

Relationship between circulating miRNA-30e and no-reflow phenomenon in STEMI patients undergoing primary coronary intervention

To investigate the relationship between miRNA-30e level in circulation and no-reflow phenomenon in patients with acute ST-segment elevation myocardial infarction (STEMI) during primary percutaneous coronary intervention (pPCI). A total of 255 consecutive patients with STEMI undergoing pPCI were enrolled in this study. These patients were divided into two groups according to the occurrence of reflow during pPCI, namely normal-reflow group with 214 cases and no-reflow group with 41 cases. The plasma levels of miRNA-30e were quantified using real-time quantitative polymerase chain reaction. The plasma levels of miRNA-30e were significantly lower in the no-reflow group as compared to the normal-reflow group (p?p?p?=?.034), hs-CRP (OR?=?1.353, 95% CI 1.129–1.635, p?=?.012) and Killip class ≥2 at admission (OR?=?1.263, 95% CI 1.023–1.532, p?=?.027), were independent risk factors for no-reflow during pPCI. When plasma miRNA-30e level was used as the test variable, the area under the curve was 0.914 (p?相似文献   

超声心动图用于非瓣膜病性心房颤动患者卒中危险分层

目的观察超声心动图用于非瓣膜病性心房颤动(NVAF)患者卒中危险分层的价值。方法根据CHA₂ DS₂-VASc评分将90例NVAF患者分为低危组(17例)、中危组(40例)及高危组(33例),对比其血清脑钠肽(BNP)、肌钙蛋白Ⅰ(TnⅠ)及超声参数左心房前后径(LAD)、左心房容积指数(LAVI)、二尖瓣口舒张期流速(E)、二尖瓣环舒张期运动速度(e’)和左心耳(LAA)排空速度(V LAA)、口部直径(D 1)、内侧壁应变(S内)和外侧壁应变(S外)等。结果高危组BNP明显高于中、低危组(P均<0.05),高危组TnⅠ明显高于低危组(P<0.05)。高危组LAVI明显高于中危组(P<0.05),中危组LAVI明显高于低危组(P<0.05);高危组LAD、e’及E/e’均明显大于低危组(P均<0.05)。高危组V LAA明显低于中、低危组(P均<0.05),中危组V LAA明显低于低危组(P<0.05);高危组D 1、S内及S外均明显高于低危组(P均<0.05)。结论超声心动图LAVI、V LAA和LAA应变等参数对于NVAF患者卒中危险分层具有一定临床应用价值。     

Prasugrel in acute coronary syndrome patients undergoing percutaneous coronary intervention

Currently, dual antiplatelet therapy with aspirin and clopidogrel represents the key treatment strategy for the prevention of ischemic events in patients with acute coronary syndrome (ACS) and/or undergoing percutaneous coronary intervention (PCI). However, there is a broad inter-individual response variability to such treatment strategy, and a considerable number of patients persist with inadequate platelet inhibition, which has been associated with an increased risk of ischemic events. Overall, these findings underscore the need for novel antiplatelet agents able to achieve greater platelet inhibition; this can potentially reduce ischemic event rates. Prasugrel (CS-747; LY 640315), a novel third-generation oral thienopyridine, is a specific, irreversible antagonist of the platelet adenosine diphosphate P2Y₁₂ receptor. Laboratory studies have shown prasugrel to be associated with more prompt, potent and predictable degrees of platelet inhibition compared with clopidogrel. In a large-scale clinical study, which was comprised of high-risk ACS patients undergoing PCI, prasugrel was shown to significantly reduce the short- and long-term risk of ischemic events, including stent thrombosis. However, such significant reduction in ischemic events occurred at the expense of a higher risk of bleeding. Recent clinical trial data analyses have led to a better understanding of the efficacy and safety of prasugrel. This article reviews the currently available data regarding the efficacy and safety of prasugrel in ACS patients.     

Genetic testing in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a cost‐effectiveness analysis

Summary. Background: The CYP2C19 genotype is a predictor of adverse cardiovascular events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) treated with clopidogrel. Objectives: We aimed to evaluate the cost‐effectiveness of a CYP2C19*2 genotype‐guided strategy of antiplatelet therapy in ACS patients undergoing PCI, compared with two ‘no testing’ strategies (empiric clopidogrel or prasugrel). Methods: We developed a Markov model to compare three strategies. The model captured adverse cardiovascular events and antiplatelet‐related complications. Costs were expressed in 2010 US dollars and estimated using diagnosis‐related group codes and Medicare reimbursement rates. The net wholesale price for prasugrel was estimated as $5.45 per day. A generic estimate for clopidogrel of $1.00 per day was used and genetic testing was assumed to cost $500. Results: Base case analyses demonstrated little difference between treatment strategies. The genetic testing‐guided strategy yielded the most QALYs and was the least costly. Over 15 months, total costs were $18 lower with a gain of 0.004 QALY in the genotype‐guided strategy compared with empiric clopidogrel, and $899 lower with a gain of 0.0005 QALY compared with empiric prasugrel. The strongest predictor of the preferred strategy was the relative risk of thrombotic events in carriers compared with wild‐type individuals treated with clopidogrel. Above a 47% increased risk, a genotype‐guided strategy was the dominant strategy. Above a clopidogrel cost of $3.96 per day, genetic testing was no longer dominant but remained cost‐effective. Conclusions: Among ACS patients undergoing PCI, a genotype‐guided strategy yields similar outcomes to empiric approaches to treatment, but is marginally less costly and more effective.     

Outcome after coronary artery bypass surgery and percutaneous coronary intervention in patients with atrial fibrillation and oral anticoagulation

Abstract

Aim. This study was planned to compare the clinical characteristics and outcome of patients on warfarin treatment for atrial fibrillation (AF) undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI).

Methods. This is a retrospective analysis of 121 patients who underwent isolated CABG and 301 patients who underwent PCI.

Results. PCI patients were older (mean age, 72.9 versus 69.8 years) and more often had prior cardiac surgery (15.9% versus 1.7%) and acute coronary syndrome (53.8% versus 21.5%). CABG patients more often had two- and three-vessel disease (95.0% versus 60.2%) and left main stenosis (32.2% versus 7.0%). The 30-day outcome was similar after PCI and CABG. At 3 years, PCI was associated with lower overall survival (72.0% versus 86.4%, P = 0.006), freedom from repeat revascularization (85.3% versus 98.2%, P < 0.001), freedom from myocardial infarction (83.4% versus 93.8%, P = 0.008), and freedom from major cardiovascular events (57.4% versus 78.9%, P < 0.001). Propensity score adjusted analysis showed that PCI was associated with increased risk of all-cause mortality (P = 0.016, RR 2.166, CI 1.155–4.060), myocardial infarction (P = 0.017, RR 3.161, 95% CI 1.227–8.144), repeat revascularization (P = 0.001, RR 13.152, 95% CI 2.799–61.793), and major cardiac and cerebrovascular complications (P = 0.001, RR 2.347, 95% CI 1.408–3.914). There was no difference in terms of stroke and bleeding episodes at any time point.

Conclusion. In clinical practice, PCI is the preferred revascularization strategy in these frail patients. Patients selected for CABG have a relatively low operative risk and better mid-term outcome in spite of warfarin treatment. The poor prognosis after PCI may mainly reflect frequent co-morbidities in this patient group.