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Background: The patterns of late major bleeding (MB) after percutaneous coronary intervention (PCI) remain unknown in Chinese patients. Objectives: This study sought to determine the incidence, prediction, and long-term outcomes of late MB in Chinese patients. Methods: This was a retrospective cohort study from 14 hospitals in Hong Kong. Participants were patients undergoing first-time PCI without MB within 30 days or death within 1 year. Patients were stratified by the presence of late MB, defined as MB between 30 and 365 days. The primary endpoint was all-cause mortality. The secondary endpoints were major adverse cardiac events (MACE). Results: A total of 32,057 patients were analyzed. After adjustment for baseline characteristics, periprocedural characteristics, and medications on discharge, the risks of all-cause mortality at 5 years were significantly higher with late MB (HR: 2.15; 95% CI: 1.92-2.41; P < 0.001). Late MB was also associated with a higher risk of MACE (HR: 1.57; 95% CI: 1.03-1.50; P < 0.001), myocardial infarction (HR: 1.25; 95% CI: 1.04-1.52; P = 0.02), and stroke (HR: 1.38; 95% CI: 1.09-1.73; P = 0.006). The CARDIAC (anti-Coagulation therapy, Age, Renal insufficiency, Drop In hemoglobin, baseline Anemia in Chinese patients) score had a good discriminating power for prediction of MB within 365 days (area under the receiver-operating characteristic curve: 0.76). Conclusions: Late MB was independently associated with a higher risk of mortality, MACE, myocardial infarction, and stroke in patients undergoing PCI. The CARDIAC score is a simple model that can predict MB after PCI. Prevention of MB represents an important strategy to optimize cardiovascular outcomes for patients undergoing PCI.
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Background: There is a significant disparity between randomized controlled trials and observational studies with respect to any mortality benefit with intracoronary imaging during the percutaneous coronary intervention (PCI). This raises a suspicion that the imaging paradox, in which some operators may become over reliant on imaging and less proficient with angiography-guided PCI, might exist. Method: This was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between January 1, 2010 and December 31, 2017. Participants were patients who underwent first-ever PCI. The association between mortality risks of patients undergoing angiography-guided PCI and three tertiles (low, medium, and high) of the proportion of PCI done under intracoronary imaging guidance at a population level (background imaging rate), were evaluated after confounder adjustment by multivariable logistic regression. Results: In an adjusted analysis of 11,816 patients undergoing angiography-guided PCI, the risks of all-cause mortality for those were higher in the high-tertile group compared with the low-tertile group (OR, 1.45, 95% CI, 1.10-1.92, P = 0.008), the risks of cardiovascular mortality were higher in the high-tertile group compared with the low-tertile group (OR, 1.51, 95% CI, 1.08-2.13, P = 0.017). The results were consistent with multiple sensitivity analyses. Threshold analysis suggested that the mortality risks of angiography-guided PCI were increased when the proportion of imaging-guided PCI exceeded approximately 50%. Conclusions: The risks of the all-cause mortality and cardiovascular mortality were higher for patients undergoing angiography-guided PCI in practices with a higher background imaging rate.
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BACKGROUND: The impact of contrast-induced acute kidney injury (CI-AKI) on long-term major adverse cardiovascular events (MACE) remains controversial. METHOD: This was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between 2004 and 2017. Severe CI-AKI was defined as an increase in serum creatinine of >50% from the baseline value, an absolute increase of >1 mg/dL (88 µmol/L) or requiring dialysis after percutaneous coronary intervention (PCI). Mild CI-AKI was defined as an increase in serum creatinine of >25% from the baseline value or an absolute increase of >0.5 mg/dL (44 µmol/L) after PCI but not fulfilling the criteria for severe CI-AKI. The primary endpoint was MACE, defined as a composite outcome of all-cause mortality, non-fatal myocardial infarction after hospital discharge, stroke or any unplanned coronary revascularization, in a time-to-first-event analysis up to 5 years after PCI. The secondary endpoints were individual components of MACE and cardiovascular mortality. RESULTS: A total of 34 576 patients were analysed. After adjustment for cardiovascular risk factors, procedural characteristics and medication use, the risk of MACE at 5 years was significantly higher with mild CI-AKI {hazard ratio [HR], 1.18 [95% confidence interval (CI) 1.12-1.26); P < 0.001} and severe CI-AKI [HR 1.92 (95% CI 1.78-2.07); P < 0.001]. Severe CI-AKI was associated with higher adjusted risks of each secondary end point and the risks monotonically accrued over time. CONCLUSIONS: Among patients undergoing a first-ever PCI, CI-AKI of any severity was associated with a higher adjusted risk of MACE at 5 years. Severe CI-AKI has a stronger association with MACE and its individual components, with an excess of early and late events.
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BACKGROUND: The choice of antithrombotic therapy after percutaneous coronary intervention (PCI) is heavily dependent on the relative trade-off between major bleeding (MB) and myocardial infarction (MI). However, the mortality trade-off was mostly described in Western populations and remained unknown in East Asians. METHOD: This was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between 2004 and 2017. Participants were patients undergoing first-time PCI and survived for the first year. Patients were stratified by the presence of MB and MI during the first year. The primary endpoint was all-cause mortality between 1 and 5 years after PCI. The secondary endpoint was cardiovascular mortality. RESULTS: A total of 32 180 patients were analysed. After adjustment for baseline characteristics and using patients with neither events as reference, the risks of all-cause mortality were increased in patients with MI only (HR, 1.63; 95% CI 1.45 to 1.84; p<0.001), further increased in those with MB only (HR, 2.11, 95% CI 1.86 to 2.39; p<0.001) and highest in those with both (HR, 2.92; 95% CI 2.39 to 3.56; p<0.001). In both Cox regression and propensity score analyses, MB had a stronger impact on all-cause mortality than MI, but similar impact on cardiovascular mortality. CONCLUSIONS: Both MB and MI within the first year after PCI were associated with increase in all-cause and cardiovascular mortality in Chinese patients, but the impact was stronger with MB.
