Ischemic and bleeding risk after complex percutaneous coronary intervention in patients with or without high bleeding risk

Abstract

Objectives To evaluate utility of the complex percutaneous coronary intervention (PCI) criteria in real‐world practice. Background Applicability of procedural complexity criteria for risk stratification has not been adequately evaluated in real‐world practice. Methods Among 13,087 patients undergoing first PCI in the CREDO‐Kyoto registry cohort‐2, the study population consisted of 7,871 patients after excluding patients with acute myocardial infarction and those without stent implantation. Complex PCI was defined as PCI, which fulfills at least one of the followings: three vessels treated, > = 3 stents implanted, > = 3 lesions treated, bifurcation with two stents, >60 mm total stent lengths, and target of chronic total occlusion. Results The cumulative incidences of and adjusted risks for the primary ischemic (myocardial infarction/ischemic stroke), and bleeding (GUSTO moderate/severe) endpoints were significantly higher in patients with complex PCI (N = 2,777 [35%]) than in those with noncomplex PCI (N = 5,094 [65%]) (15.4% vs. 10.9%, log‐rank p < .001; odds ratio (OR): 1.53, 95% confidence interval (CI): 1.31–1.79, p < .001, and 11.9% vs. 9.9%, log‐rank p = .004; OR: 1.24, 95% CI: 1.05–1.46, p = .01). In the 30‐day landmark analysis, the higher risks of patients with complex PCI for ischemic and major bleeding events were only seen within 30 days after PCI (ischemic; within 30 days: HR: 2.19, 95% CI: 1.79–2.69, p < .001; beyond 30 days: HR: 1.11, 95% CI: 0.92–1.34, p = .26, and bleeding; within 30 days: HR: 1.56, 95% CI: 1.13–2.16, p = .007; beyond 30 days: HR: 1.11, 95% CI: 0.94–1.31, p = .22). Conclusions Patients with complex PCI as compared with patients with noncomplex PCI had a higher risk for both ischemic and bleeding events mainly within 30 days after PCI.

Impact of complex percutaneous coronary intervention features on clinical outcomes in patients with or without chronic kidney disease

“…The effects of CPCI in no‐CKD patients observed in our analysis were consistent with the findings of two large multicenter registries, ADAPT‐DES and CREDO‐Kyoto, in which no‐CKD patients represented about 80% and 60% of the population, respectively. In both studies, CPCI was associated with a > 70% higher risk of MI, stent thrombosis or recurrent coronary revascularization, a 20%−30% risk increase of major bleeding but not with an increased mortality 13,14 . On the other hand, in other registries including complex or noncomplex PCI, the presence of CKD was associated with a > 2‐time higher hazard of both ischemic and bleeding events as well as an increased mortality 9,10 …”

“…CPCI represents approximately 30% of contemporary PCI 12,[26][27][28][29] and it is related with higher risk of recurrent ischemic events. 13,14,17,30 Very limited data exists regarding the prevalence and prognostic impact of CPCI in CKD patients. This information is crucial to better understand the most appropriate management, including the optimal antiplatelet treatment regimen, of this subset of patients.…”

“…About 30% of contemporary PCIs performed are complex; estimates may vary across studies partly because a universal definition for CPCI is lacking 12 . In the few studies reporting this information, the prevalence of CPCI ranged between 20% and 40% in the CKD population 13,14 . Complex PCI has been associated with higher risk of ischemic and in less extent of bleeding complications in all‐comers cohorts 15 .…”

“…12 In the few studies reporting this information, the prevalence of CPCI ranged between 20% and 40% in the CKD population. 13,14 Complex PCI has been associated with higher risk of ischemic and in less extent of bleeding complications in all-comers cohorts. 15 Conversely, data on the prevalence and prognostic impact of CPCI in patients with CKD is limited.…”

Prognostic and Practical Validation of ESC/EACTS High Ischemic Risk Definition on Long-Term Thrombotic and Bleeding Events in Contemporary PCI Patients

“…Eligibility criteria across these trials have limited the inclusion of HIR patients, so the majority of enrolled patients had low or intermediate ischemic risk. In real-world clinical practice, physicians are still reluctant to choose very short DAPT durations for HIR patients, mainly due to concerns on their higher risk for atherothrombotic ischemic events 10,[40][41][42] . Indeed, we observed that patients who remained on DAPT at 1 year and 2 years, as expected, were more common among patients with HIR than in the non-HIR group.…”