RESUMO
BACKGROUND: Women undergoing percutaneous coronary intervention (PCI) are at higher risk for bleeding and vascular complications than men. Multiple approaches have been utilized to reduce bleeding in the modern era of PCI, including radial access, reduced GP IIb/IIIa inhibitor use, increased vascular closure device use, smaller sheath size and novel antithrombotic regimens. Nevertheless, few studies have assessed the impact of these techniques on the gap between men and women for such complications following PCI. We sought to quantify bleeding and vascular complications over time between men and women. METHODS: We queried The Dartmouth Dynamic Registry for consecutive PCI's performed between January 2003 and June 2016. Demographic information, procedural characteristics, and in-hospital outcomes were collected and compared between men and women over the years. RESULTS: We reviewed 15,284 PCI cases, of which 4384 (29%) were performed in women. Radial access increased from none in 2003 to nearly 40% in 2016. Use of GP IIb/IIIa and femoral access decreased substantially over the same time. Bleeding and vascular complication rates decreased significantly in women (13.2% to 3%; 6.5% to 0.8%, respectively) and men (3.5% to 0.7%, 3.4% to 0.7%, respectively). The overall bleeding and vascular complication rates decreased more for women than men, narrowing the gender gap. CONCLUSIONS: The incidence of bleeding and vascular complications fell between 2003 and 2016 in both men and women. Vascular complications have become less common over time, and based on our analysis, there was no longer any difference between the sexes for this outcome. Bleeding following PCI has decreased in both sexes over time; however, women continue to bleed more than men.
Assuntos
Intervenção Coronária Percutânea , Feminino , Humanos , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Artéria Radial/diagnóstico por imagem , Sistema de Registros , Fatores de Risco , Caracteres Sexuais , Resultado do TratamentoRESUMO
Current generation durable polymer DES have sustained efficacy and safety out to 5 years. The Orsiro DES has both a bioresorbable polymer and ultra thin struts and has the potential to improve the safety of DES. In this all comers trial, 3 year outcomes with Orsiro DES were similar to the durable polymer zotarolimus eluting stent.
Assuntos
Stents Farmacológicos , Intervenção Coronária Percutânea , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Polímeros , Desenho de Prótese , Sirolimo/análogos & derivados , Resultado do TratamentoRESUMO
BACKGROUND: Very elderly patients (age ≥ 85 years) are a rapidly increasing segment of the population. As a group, they experience high rates of in-hospital mortality and bleeding complications following percutaneous coronary intervention (PCI). However, the relationship between bleeding and mortality in the very elderly is unknown. METHODS: Retrospective review was performed on 17,378 consecutive PCI procedures from 2000 to 2015 at Dartmouth-Hitchcock Medical Center. Incidence of bleeding during the index PCI admission (bleeding requiring transfusion, access site hematoma > 5 cm, pseudoaneurysm, and retroperitoneal bleed) and in-hospital mortality were reported for four age groups (< 65 years, 65-74 years, 75-84 years, and ≥ 85 years). The mortality of patients who suffered bleeding complications and those who did not was calculated and multivariate analysis was performed for in-hospital mortality. Lastly, known predictors of bleeding were compared between patients age < 85 years and age ≥ 85 years. RESULTS: Of 17,378 patients studied, 1019 (5.9%) experienced bleeding and 369 (2.1%) died in-hospital following PCI. Incidence of bleeding and in-hospital mortality increased monotonically with increasing age (mortality: 0.94%, 2.27%, 4.24% and 4.58%; bleeding: 3.96%, 6.62%, 10.68% and 13.99% for ages < 65, 65-74, 75-84 and ≥ 85 years, respectively). On multivariate analysis, bleeding was associated with increased mortality for all age groups except patients age ≥ 85 years [odds ratio (95% CI): age < 65 years, 3.65 (1.99-6.74); age 65-74 years, 2.83 (1.62-4.94); age 75-84 years, 3.86 (2.56-5.82), age ≥ 85 years: 1.39 (0.49-3.95)]. CONCLUSIONS: Bleeding and mortality following PCI increase with increasing age. For the very elderly, despite high rates of bleeding, bleeding is no longer predictive of in-hospital mortality following PCI.
RESUMO
OBJECTIVE: The choice of antithrombotic agent used during percutaneous coronary intervention (PCI) is controversial. While earlier studies suggested a reduction in bleeding events with bivalirudin, these studies were confounded by the concomitant use of glycoprotein IIbIIIa inhibitors (GPI) in the heparin group. More recent studies have challenged the superiority of bivalirudin, pointing to an increased risk of stent thrombosis. Real-world data remains limited. METHODS: We queried our institutional catheterization laboratory database for all PCI cases performed between January 2003 and December 2012 using only heparin or only bivalirudin (no use of GPI). We collected data on relevant patient and procedural characteristics and compared both efficacy and safety outcomes. We adjusted for baseline differences using coarsened exacting matching. RESULTS: 8061 cases met our inclusion criteria. Of these, 34.9% were performed with heparin alone and 65.1% with bivalirudin. After adjusting for baseline differences, we found that those patients receiving heparin had a slightly lower risk of post-procedural abrupt vessel closure (0.1% vs 0.5%). All other outcomes favored bivalirudin including procedural success (97.2% vs 95.5%), transfusion within 72h (2.2% vs 4.8%), retroperitoneal bleeding (0.1% vs 0.8%), and all-cause mortality (0.9% vs 1.9%). Subgroup analysis suggested that outcomes were different only in non-elective cases and non STEMI cases. CONCLUSION: Heparin appears to offer the advantage of slightly reduced risk of abrupt vessel closure post-procedure but at the cost of increased hemorrhagic complications and all-cause mortality. This difference in outcomes may be limited to non-elective and non STEMI cases with femoral access.
Assuntos
Anticoagulantes/administração & dosagem , Antitrombinas/administração & dosagem , Doença da Artéria Coronariana/cirurgia , Heparina/administração & dosagem , Hirudinas/administração & dosagem , Infarto do Miocárdio/cirurgia , Fragmentos de Peptídeos/administração & dosagem , Intervenção Coronária Percutânea , Idoso , Anticoagulantes/efeitos adversos , Antitrombinas/efeitos adversos , Causas de Morte , Tomada de Decisão Clínica , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Bases de Dados Factuais , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Heparina/efeitos adversos , Hirudinas/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , New Hampshire , Fragmentos de Peptídeos/efeitos adversos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação Plaquetária/administração & dosagem , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Stents , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: To determine whether exercise performance changed over time once patients stabilized after heart transplantation, metabolic stress testing was performed in patients one and two yr post-heart transplantation. METHODS: The patient cohort includes those transplanted in our program who survived at least two yr and were able to perform metabolic stress tests during their one- and two-yr annual evaluations. Standard stress test parameters were assessed, including weight, body surface area, rest and exercise heart rate (HR) and blood pressure (BP), exercise time, anaerobic threshold (AT), and maximum VO2 (MVO2). Ejection fraction by echo was also collected. Each patient served as their own control and data were compared using paired t-testing. RESULTS: Fifty patients were included in the cohort, 48 of whom were able to exercise to at least AT. Patient weight increased from year 1 to year 2 (82.4 ± 15.1 vs. 85.0 ± 17.0 kg, p = 0.035). Systolic BP increased approximately 40 mmHg with exercise with no change in diastolic BP, and there was no difference between years 1 and 2. HR increased approximately 25 bpm with exercise. There was no difference in resting HR but exercise HR increased significantly between yrs (148 ± 15 bpm vs. 154 ± 18 bpm, p = 0.017). Both VO2 at AT and MVO2 increased significantly from year 1 to year 2 (1116 ± 347 mL/min vs. 1192 ± 313 mL/min, p = 0.049 and 1523 ± 337 mL/min vs. 1599 ± 356 mL/min, p = 0.012, respectively) but when corrected for body weight, there were no differences (VO2-AT 13.6 ± 4.0 mL/kg/min vs. 14.0 ± 4.0 mL/kg/min; MVO2 18.7 ± 4.2 mL/kg/min vs. 18.8 ± 4.1 mL/kg/min). All other measured parameters were not different. There was a weak but statistically significant correlation between change in peak HR and change in VO2 at AT between one and two yr post-transplantation (r = 0.30, p = 0.04). CONCLUSIONS: We conclude that exercise performance as measured by VO2 can increase over time post-heart transplantation and in our cohort appears to be related to both an increase in body weight and an increase in HR from years 1 and 2.