Sex differences in distribution, management and outcomes of combined ischemic-bleeding risk following acute coronary syndrome

Mohamed, Mohamed; Rashid, Muhammad; Clarke, Sarah; Lawson, Claire; Michos, Erin D.; Kwok, Chun Shing; Belder, Mark de; Valgimigli, Marco

doi:10.1016/j.ijcard.2020.12.063

Cited by 10 publications

(4 citation statements)

References 32 publications

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“…ACS patients often present with risk factors for both ischemia and bleeding event, and certain risk factors can potentially trigger both of these adverse event types. Mohamed et al (10) found that one in three ACS patients exhibited high-risk factors for both bleeding and ischemic events while also observing higher rates of major adverse cardiovascular events (MACE; cardiac death and reinfarction) and all-cause bleeding events as compared to non-bi-risk patients, in line with the present results. However, in the current study cohort, 58.8% of patients were classified as bi-risk individuals, since prior studies have included bi-risk patients among the overall ACS patient population.…”

Section: Discussionsupporting

confidence: 90%

Effect of dual antiplatelet therapy prolongation in acute coronary syndrome patients with both high ischemic and bleeding risk: insight from the OPT-CAD study

Na,

Qiu,

Wei

et al. 2023

Front. Cardiovasc. Med.

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BackgroundIn current clinical practice, controversy remains regarding the clinical benefits of prolonged dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) patients facing high risks of both ischemia and bleeding (“bi-risk”) following percutaneous coronary intervention (PCI). This study aimed to investigate the feasibility of identifying a group of bi-risk ACS patients after PCI using the OPT-BIRISK criteria, emphasizing extended DAPT treatment safety and efficacy beyond 12 months in these bi-risk ACS after PCI in real-world conditions.MethodsThis analysis compared extended DAPT and single antiplatelet therapy (SAPT) at 12–24 months in ACS patients undergoing PCI complicated with both ischemic and bleeding risk as defined by OPT-BIRISK criteria without premature DAPT discontinuation before 9 months or major clinical adverse events within 12 months. This was a post hoc analysis of the Optimal antiPlatelet Antiplatelet Therapy for Chinese Patients with Coronary Artery Disease (OPT–CAD) study. The main research outcome was the incidence of ischemic events within 12–24 months, which was determined as a composite of stroke, myocardial infarction, and cardiac death events. Through propensity score matching (PSM), groups were balanced. For the external validation of the OPT-BIRISK criteria to identify a bi-risk ACS patient, ischemic events, BARC 2, 3, 5 bleeding events, and BARC 3, 5 bleeding events at 5 years were analyzed.ResultsThe total number of ACS patients analyzed in this analysis was 7,049, of whom 4,146 (58.8%) were bi-risk patients and 2,903 (41.2%) were not. The frequency of ischemic events was significantly different between the two groups at 5 years (11.70% vs. 5.55%, P < 0.001), and the incidence of BARC 2,3,5 bleeding was significantly higher in the bi-risk group (6.90% vs. 4.03%, P < 0.001) than in the non-bi-risk group. Among the bi-risk patients without any clinical adverse events within 12 months that underwent extended DAPT treatment (n = 2,374, 75.7%) exhibited a lower risk of stroke at 12–24 months (1.10% vs. 2.10%, P = 0.036) relative to those that underwent SAPT (n = 763, 24.3%), while bleeding risk did not differ significantly between these groups. PSM cohort analysis results were consistent with those of overall group analyses.ConclusionIn conclusion, the findings showed that using the OPT-BIRISK criteria could help physicians identify ACS patients at a high risk of developing recurrent ischemia and bleeding episodes after PCI. Compared to antiplatelet monotherapy, a strategy of extended DAPT may offer potential benefits in lowering the risk of stroke without carrying a disproportionately high risk of serious bleeding problems among these patients who were event-free after a year of DAPT.

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Section: Discussionsupporting

confidence: 90%

Effect of dual antiplatelet therapy prolongation in acute coronary syndrome patients with both high ischemic and bleeding risk: insight from the OPT-CAD study

Na,

Qiu,

Wei

et al. 2023

Front. Cardiovasc. Med.

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“…As demonstrated in a retrospective cohort study of patients with AMI, fewer women had undergone revascularization of any type, even after matching for age and type of AMI with men ( 18 ). Likewise, in patients with ACS and concomitant high bleeding risk and high ischemic risk, guideline-recommended therapy (including revascularization and DAPT) was given less often to women than men with similar risk profiles [ 19 ]. In another report on patients with AMI, a higher proportion of men than women received mechanical circulatory support, despite a higher percentage of women presenting with cardiogenic shock [ 20 ].…”

Section: Discussionmentioning

confidence: 99%

Sex differences following percutaneous coronary intervention or coronary artery bypass surgery for acute myocardial infarction

Lin

Lee

et al. 2022

Biol Sex Differ

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Background Women have been underrepresented in the literature; the effects of female sex on outcomes in patients with acute myocardial infarction (AMI) remain unclear. Objectives This study compares the real-world outcomes of women and men with AMI who have undergone revascularization via percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). Methods This is a retrospective cohort study utilizing data from the Taiwan National Health Insurance database. We identified patients who were admitted for AMI and who underwent coronary revascularization during the index admission period between January 1, 2001, and December 31, 2013. Patients were then categorized based on the treatment received into PCI and CABG groups. In-hospital and long-term outcomes were compared between women and men in each group. Interaction tests were then performed to determine whether the differences between sexes were modified by the mode of revascularization. Analyses were repeated after propensity score matching between women and men in each group to minimize possible confounders. We also conducted subgroup analyses, stratifying by the presence of diabetes mellitus, congestive heart failure, and chronic kidney disease. Results We enrolled 67,534 patients who met the inclusion criteria in the analysis; 60,207 patients had undergone PCI (13,514 female and 46,693 male), while 7327 patients had received CABG (1762 female and 5565 male). Prior to matching, enrolled female patients were older on average, with more comorbidities. In-hospital and long-term outcomes were worse in women, particularly in the PCI group. After matching, the incidence of hospitalization for heart failure (HHF) was higher in women (10.4% vs 8.0%, OR 1.32, 95% CI 1.22–1.43), with fewer repeat revascularizations (28.1% vs 32.4%, OR 0.84, 95% CI 0.81–0.88). Both observations were more pronounced in the PCI group (HHF: P for interaction = 0.0496; repeat revascularization: P for interaction = 0.021). Conclusions Women presenting with AMI exhibited worse in-hospital and long-term outcomes than men, especially among women who received PCI as the initial mode of revascularization. Women who underwent PCI were more likely to be admitted for heart failure during follow-up. Possible socioeconomic inequalities or a distinct pathobiology of cardiac ischemia between sexes may underlie these results; thus, further investigation is needed.

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“…Therefore, it is crucial to assess the factors associated with bleeding risk. As advanced age (21) and female sex (22) are associated with increased bleeding risk, primary physicians of these patients might prefer clopidogrel, which could explain the significant differences in age and male sex between the prasugrel/ticagrelor and clopidogrel groups. However, there was no correlation between hemoglobin fall ≥3 g/dL and age, sex, or antiplatelet agent used.…”

Section: Discussionmentioning

confidence: 99%

Bleeding risk with concomitant use of tirofiban and third-generation P2Y12 receptor antagonists in patients with acute myocardial infarction: A real-life data

Tigen¹,

Ozdil²,

Cincin³

et al. 2021

The Anatolian Journal of Cardiology

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Objective: Combination of dual antiplatelet therapy (DAPT) with glycoprotein (GP) IIb/IIIa inhibitors can increase bleeding risk. In this study, we aimed to investigate bleeding complications of different DAPTs with concomitant tirofiban use in patients with acute coronary syndrome (ACS). Methods: This retrospective study included 224 consecutive ACS patients (mean age 56.6±11.1 years, 193 men) who were given conventional dose of tirofiban (25 µg/kg per 3 minutes followed by an infusion of 0.15 µg/kg/min for 24 hours) in addition to DAPT (300 mg aspirin followed by 100 mg/day + 600 mg clopidogrel followed by 75 mg/day or 180 mg ticagrelor followed by 90 mg twice daily or 60 mg prasugrel followed by 10 mg/day). Any intra-hospital bleeding complications were noted. Results: Of the 224 patients, 115 were given ticagrelor and 32 were given prasugrel. Mean hemoglobin fall was similar between the patients taking ticagrelor/prasugrel and those taking clopidogrel. Ten patients taking ticagrelor and one patient taking prasugrel had hemoglobin fall ≥3 g/dL versus two patients in clopidogrel group (p=0.228). Gastrointestinal bleeding (two patients taking ticagrelor), hematoma at access site (three patients taking ticagrelor), and cardiac tamponade (two patients taking ticagrelor) rates were also similar. Creatinine levels were associated with hemoglobin fall ≥3 g/dL (p=0.032, Odds ratio 2.189, 95% confidence interval 1.070-4.479). There was no relation between hemoglobin fall ≥3 g/dL and antiplatelet agent, age, sex, hypertension, or diabetes. Conclusion: Tirofiban may be given to patients receiving ticagrelor or prasugrel with a bleeding rate similar to clopidogrel. Close monitoring for bleeding risk is recommended, especially in patients with higher creatinine levels.

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Sex differences in distribution, management and outcomes of combined ischemic-bleeding risk following acute coronary syndrome

Cited by 10 publications

References 32 publications

Effect of dual antiplatelet therapy prolongation in acute coronary syndrome patients with both high ischemic and bleeding risk: insight from the OPT-CAD study

Effect of dual antiplatelet therapy prolongation in acute coronary syndrome patients with both high ischemic and bleeding risk: insight from the OPT-CAD study

Sex differences following percutaneous coronary intervention or coronary artery bypass surgery for acute myocardial infarction

Bleeding risk with concomitant use of tirofiban and third-generation P2Y12 receptor antagonists in patients with acute myocardial infarction: A real-life data

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