Direct comparison of predictive performance of PRECISE-DAPT versus PARIS versus CREDO-Kyoto: a subanalysis of the ReCre8 trial.

BACKGROUND: Multiple scores have been proposed to guide risk stratification after percutaneous coronary intervention. This study assessed the performance of the PRECISE-DAPT, PARIS and CREDO-Kyoto risk scores to predict post-discharge ischaemic or bleeding events. METHODS: A total of 1491 patients treated with latest-generation drug-eluting stent implantation were evaluated. Risk scores for post-discharge ischaemic or bleeding events were calculated and directly compared. Prognostic performance of both risk scores was assessed with calibration, Harrell's c­statistics net reclassification index and decision curve analyses. RESULTS: Post-discharge ischaemic events occurred in 56 patients (3.8%) and post-discharge bleeding events in 34 patients (2.3%) within the first year after the invasive procedure. C­statistics for the PARIS ischaemic risk score was marginal (0.59, 95% confidence interval (CI) 0.51-0.68), whereas the CREDO-Kyoto ischaemic risk score was moderate (0.68, 95% CI 0.60-0.75). With regard to post-discharge bleeding events, CREDO-Kyoto displayed moderate discrimination (c-statistic 0.67, 95% CI 0.56-0.77), whereas PRECISE-DAPT (0.59, 95% CI 0.48-0.69) and PARIS (0.55, 95% CI 0.44-0.65) had a marginal discriminative capacity. Net reclassification index and decision curve analysis favoured CREDO-Kyoto-derived bleeding risk assessment. CONCLUSION: In this contemporary all-comer population, PARIS and PRECISE-DAPT risk scores were not resilient to independent testing for post-discharge bleeding events. CREDO-Kyoto-derived risk stratification was associated with a moderate predictive capability for post-discharge ischaemic or bleeding events. Future studies are warranted to improve risk stratification with more focus on robustness and rigorous testing.

Incidence, angiographic and clinical predictors, and impact of stent thrombosis: a 6-year survey of 6,545 consecutive patients.

OBJECTIVE: We sought to determine the incidence, angiographic predictors, and impact of stent thrombosis (ST). BACKGROUND: Given the high mortality after ST, this study emphasises the importance of ongoing efforts to identify angiographic predictors of ST. METHODS: All consecutive patients with angiographically confirmed ST between 2010 and 2016 were 1:4 matched for (1) percutaneous coronary intervention (PCI) indication and (2) index date ±6 weeks to randomly selected controls. Index PCI angiograms were reassessed by two independent cardiologists. A multivariable conditional logistic regression model was built to identify independent predictors of ST. RESULTS: Of 6,545 consecutive patients undergoing PCI, 55 patients [0.84%, 95% confidence interval (CI) 0.63-1.10%] presented with definite ST. Multivariable logistic regression identified dual antiplatelet therapy (DAPT) non-use as the strongest predictor of ST (odds ratio (OR) 10.9, 95% CI 2.47-48.5, p < 0.001), followed by: stent underexpansion (OR 5.70, 95% CI 2.39-13.6, p < 0.001), lesion complexity B2/C (OR 4.32, 95% CI 1.43-13.1, p = 0.010), uncovered edge dissection (OR 4.16, 95% CI 1.47-11.8, p = 0.007), diabetes mellitus (OR 3.23, 95% CI 1.25-8.36, p = 0.016), and residual coronary artery disease at the stent edge (OR 3.02, 95% CI 1.02-8.92, p = 0.045). ST was associated with increased rates of mortality as analysed by Kaplan-Meier estimates (27.3 vs 11.3%, plog-rank < 0.001) and adjusted Cox proportional-hazard regression (hazard ratio 2.29, 95% CI 1.03-5.10, p = 0.042). CONCLUSIONS: ST remains a serious complication following PCI with a high rate of mortality. DAPT non-use was associated with the highest risk of ST, followed by various angiographic parameters and high lesion complexity.

Short versus long duration of dual antiplatelet therapy following drug-eluting stents: a meta-analysis of randomised trials.

BACKGROUND: Dual antiplatelet therapy (DAPT) remains the cornerstone therapy in the prevention of ischaemic events following drug-eluting stent (DES) implantation. Mandatory duration of DAPT after DES however, is a matter of debate. We aimed to evaluate safety and efficacy of short-term (up to 6 months) versus long-term (12 months) DAPT after DES implantation. METHODS: We searched PubMed, EMBASE, Cochrane databases, and international meetings for randomised clinical trials (RCTs) comparing short with long DAPT. We performed a systematic review and meta-analysis of major trials with primary outcomes: all-cause death, myocardial infarction, definite or probable stent thrombosis, stroke, and major bleeding event. RESULTS: Nine RCTs with a total number of 19,099 patients were pooled in the present meta-analysis. When compared with long DAPT, short DAPT was associated with a significant reduction in major bleeding events (0.62% vs. 1.10%, risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.86, p < 0.007, I2 = 21%), whereas all-cause death (1.65% vs. 1.84%, RR 0.90, 95% CI 0.73 to 1.11, p = 0.34, I2 = 0%), myocardial infarction (1.91% vs. 1.68%, RR 1.14, 95% CI 0.92 to 1.40, p = 0.23, I2 = 0%), definite or probable stent thrombosis (0.62% vs. 0.47%, RR 1.25, 95% CI 0.84 to 1.86, p = 0.27, I2 = 0%), and stroke (0.60% vs. 0.67%, RR 0.91, 95% CI 0.63 to 1.31, p = 0.61, I2 = 0%) were similar. CONCLUSIONS: Short DAPT following DES implantation results in a significant reduction of major bleeding events with no apparent increase in all-cause death, myocardial infarction, stent thrombosis, or stroke. Future dedicated trials should investigate the optimal strategies for patient-tailored DAPT in various subgroups.

Effect of body mass index on clinical outcome and all-cause mortality in patients undergoing transcatheter aortic valve implantation.

OBJECTIVES: To assess the effect of body mass index (BMI) on outcome among patients with severe aortic stenosis (AS) admitted for transcatheter aortic valve implantation (TAVI). BACKGROUND: Being overweight or obese is associated with improved outcome following certain medical treatments, suggesting the existence of a BMI paradox. However, the relationship between BMI and mortality after TAVI remains controversial. METHODS: Patients were classified according to World Health Organisation criteria such as normal weight, overweight, or obesity according to their BMI (18.5 to 24.9 kg/m2, 25.0 to 29.9 kg/m2, and ≥30.0 kg/m2, respectively). RESULTS: A total of 549 consecutive patients (age: 80.2 ± 7.5 years; logistic European system for cardiac operative risk evaluation [EuroSCORE]: 17.3 ± 9.9%) who underwent TAVI for AS were included. Of these patients, 43% (n = 237) had normal weight, 36% (n = 200) were overweight, and 20% (n = 112) were obese. There were no differences in peri-operative bleeding or vascular complication rates between the groups. All-cause mortality after 30 days, and 1 year, were higher in normal weight patients compared with overweight and obese patients (7% vs. 5 and 4%, p = 0.383, and 19% vs. 9 and 10%, p = 0.006, respectively). After adjustment for several confounding factors, overweight was associated with a decreased 30-day and 1­year all-cause mortality outcome (hazard ratio [HR] 0.69; 95% confidence interval [CI] 0.47-0.99, and HR 0.65; 95% CI 0.45-0.94, respectively). CONCLUSIONS: Despite the well-documented adverse effects of increased body weight on health, being overweight is associated with improved survival following TAVI when compared with normal weight.

Dosing of carboplatin in a patient with amputated legs: A case report.

Carboplatin is a platinum derivative that is commonly used in combination chemotherapy for treatment of several malignancies, including small-cell lung carcinoma (SCLC). Because the estimated glomerular filtration rate, and therefore the carboplatin dose, is based on the serum creatinine level, dosing of carboplatin for amputees is a challenge. This case report describes how serum carboplatin levels were used to determine the most suitable carboplatin dose for an amputee. The patient received four cycles of etoposide in combination with carboplatin area under the curve = 5 mg·min/ml, with a dose reduction of 25% and concurrent radiotherapy. The measured area under the curve was found to be 3.41 mg·min/ml, while the target area under the curve was 3.75 mg·min/ml (75% of 5 mg·min/ml). Therefore, for the next cycles, the carboplatin dose was calculated using the Calvert formula. No recurrence of disease was seen within two years after completion of therapy. This case demonstrates that therapeutic drug monitoring can successfully be used to determine the carboplatin dose for an amputee.