Comparison of six risk scores in patients with triple vessel coronary artery disease undergoing PCI: competing factors influence mortality, myocardial infarction, and target lesion revascularization.

OBJECTIVES: To compare the discriminatory value of differing risk scores for predicting clinical outcomes following PCI in routine practice. BACKGROUND: Various risk scores predict outcomes after PCI. However, these scores consider markedly different factors, from purely anatomical (SYNTAX risk score [SRS]) to purely clinical (ACEF, modified ACEF [ACEFmod], NCDR), while other scores combine both elements (Clinical SYNTAX score [CSS], NY State Risk Score [NYSRS]). METHODS: Patients with triple vessel and/or LM disease with 12 month follow-up were studied from a single center PCI registry. Exclusion criteria included STEMI presentation, prior revascularization and shock. Clinical events at 12 months were compared to baseline risk scores, according to score tertiles and area under receiver-operating-characteristic curves (AUC). RESULTS: We identified 584 eligible patients (69.8±12.3yrs, 405 males). All scores were predictive of mortality, with the SRS being least predictive (AUC=0.66). The most accurate scores for mortality were the CSS and ACEF (AUC=0.76 for both: P = 0.019 and 0.08 vs. SRS, respectively). For TLR, while the SRS trended toward being positively predictive (P = 0.075), several scores trended towards a negative association, which reached significance for the NCDR (P = 0.045). The SRS and CSS were the only scores predictive of MI (both P < 0.05). No score was particularly accurate for predicting MACE (death+MI+TLR), with AUCs ranging from 0.53 (NCDR) to 0.63 (SRS). CONCLUSIONS: Competing factors influence mortality, MI and TLR after PCI. An increasing burden of comorbidities is associated with mortality, whereas anatomical complexity predicts MI. By combining these outcomes to predict MACE, all scores show reduced utility.

Safety of temporary and permanent suspension of antiplatelet therapy after drug eluting stent implantation in contemporary "real-world" practice.

OBJECTIVES: To define the incidence of stent thrombosis (ST) and/or AMI (ST/AMI) associated with temporary or permanent suspension of dual antiplatelet therapy (DAPT) after coronary drug-eluting stent (DES) implantation in "real-world" patients, and additional factors influencing these events. BACKGROUND: Adherence to DAPT is critical for avoiding ST following DES implantation. However, the outcomes of patients undergoing antiplatelet therapy withdrawal following DES implantation remain to be clearly described. METHODS: Patients receiving DES from 05/01/2003 to 05/01/2008 were identified from a single-center registry. Complete follow-up data were available for 5,681 patients (67% male, age 66 ± 11 years, duration 1,108 ± 446 days) who were included in this analysis. RESULTS: Uninterrupted DAPT was maintained in 4,070/5,681 (71.6%) patients, with an annual ST/AMI rate of 0.43%. Antiplatelet therapy was commonly ceased for gastrointestinal-related issues, dental procedures or noncardiac/nongastrointestinal surgery. Temporary DAPT suspension occurred in 593/5,681 (10.4%) patients for 17.6 ± 74.1 days, with 6/593 (1.0%) experiencing ST/AMI during this period. Of patients permanently ceasing aspirin (n = 187, mean 338 ± 411 days poststenting), clopidogrel (n = 713, mean 614 ± 375 days) or both agents (n = 118, mean 459 ± 408 days), ST/AMI was uncommon with an annual rate of 0.1-0.2%. Overall, independent predictors of ST/AMI were unstable initial presentation, uninterrupted DAPT and lower left ventricular ejection fraction. Factors predicting uninterrupted DAPT included diabetes, unstable presentation, prior MI, left main coronary PCI, and multivessel coronary disease. CONCLUSIONS: In real-world practice, rates of ST/AMI following DES implantation are low, but not insignificant, following aspirin and/or clopidogrel cessation. Use of uninterrupted DAPT appears more common in high-risk patients.