Decline in platelet count in patients treated by percutaneous coronary intervention: definition, incidence, prognostic importance, and predictive factors.
ABSTRACT We investigated the incidence, predictors, and prognostic impact of a decline in platelet count (DPC) in patients treated by percutaneous coronary intervention (PCI).
A total of 10 146 consecutive patients treated by PCI from 2003 to 2006 were included. According to the magnitude of the DPC, the population was divided into four groups: no DPC (<10%), minor DPC (10-24%), moderate DPC (25-49%), and severe DPC (>or=50%). The primary haemorrhagic endpoint was a composite of post-procedure surgical repair major bleeding. The primary ischaemic endpoint was 30-day all-cause mortality-non-fatal myocardial infarction. Among the total population, 36% had a DPC <10%, 47.7% had a DPC of 10-24%, 14% had a DPC of 25-49%, and 2.3% had a DPC >or=50%. On multivariate analysis, moderate and severe DPC were independent predictive factors of the ischaemic outcome. Two procedural practices were identified that, if modified, might reduce the incidence of acquired thrombocytopaenia. Both the intraprocedural use of heparin (as opposed to bivalirudin) and of low molecular weight contrast material were independently associated with severe acquired thrombocytopaenia.
Moderate and severe DPC are independent predictors of adverse bleeding and ischaemic outcomes in PCI. Adoption of intraprocedural anticoagulant other than heparin and avoidance of a low molecular weight contrast agent could potentially decrease the occurrence of severe acquired thrombocytopaenia.
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ABSTRACT: Background Bleeding following percutaneous coronary intervention (PCI) is identified as a strong predictor for adverse events, including mortality. This study aims to compare the incidence and correlates of post-PCI bleeding across different clinical presentations. Methods The study included 23943 consecutive PCI patients categorized according to their clinical presentation: stable angina pectoris (SAP, n = 6741), unstable angina pectoris (UAP, n = 5215), non-ST-segment elevation myocardial infarction (NSTEMI, n = 8418), ST-segment elevation myocardial infarction (STEMI, n = 2721), and cardiogenic shock (CGS, n = 848). Results: Severity of clinical presentation was associated with a greater use of pre-procedural anticoagulation, glycoprotein IIb/IIIa inhibitors, and intra-aortic balloon pump (IABP). Thrombolysis In Myocardial Infarction-defined major bleeding increased with increasing severity of clinical presentation: SAP, 0.7%; UAP, 1.0%; NSTEMI, 1.6%; STEMI, 4.6%; and CGS, 13.5% (p <0.001). On multivariable analysis, CGS (OR 4.67, 95% CI 2.62-8.34), STEMI (OR 3.39, 95% CI 2.07-5.55) and NSTEMI (OR 2.00, 95% CI 1.29-3.10) remained correlated with major bleeding even after adjusting for baseline and procedural differences, whereas UAP did not. The multivariable model also identified the use of IABP, female gender, congestive heart failure, no prior PCI, increased baseline hematocrit and increased procedure time as correlates for major bleeding. Conclusions In patients undergoing PCI, the worsening severity of clinical presentation corresponds to an increase in incidence of post-PCI major bleeding. The increased risk with CGS, STEMI and NSTEMI persisted despite adjusting for more aggressive pharmacotherapy and use of IABP. Careful attention to antithrombotic pharmacotherapy is warranted in this high-risk population.American Heart Journal. 01/2014;
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ABSTRACT: This study aimed to evaluate incidence and correlates for low platelet count after transcatheter aortic valve replacement (TAVR) and to determine a possible association between acquired thrombocytopenia and clinical outcomes. Patients undergoing TAVR from two medical centres were included in the study. They were stratified according to nadir platelet count post procedure: no/mild thrombocytopenia, ≥100 × 109/L; moderate, 50-99 × 109/L; and severe, <50 × 109/L. A total of 488 patients composed of the study population (age 84.7 ± 7.5 years). At a median time of 2 days after TAVR, 176 patients (36.1%) developed significant thrombocytopenia: 149 (30.5%) moderate; 27 patients (5.5%) severe. Upon discharge, the vast majority of patients (90.2%) had no/mild thrombocytopenia. Nadir platelet count <50 × 109/L was highly specific (96.3%), and a count <150 × 109/L highly sensitive (91.2%), for predicting 30-day death (C-statistic 0.76). Patients with severe acquired thrombocytopenia had a significantly higher mortality rate at 1 year (66.7% for severe vs. 16.0% for no/mild vs. 20.1% for moderate; P < 0.001). In multivariate logistic regression, severe thrombocytopenia was independently associated with 1-year mortality (hazard ratio 3.44, CI: 1.02-11.6; P = 0.046). Acquired thrombocytopenia was common after TAVR and was mostly resolved at patient discharge. The severity of thrombocytopenia after TAVR could be used as an excellent, easily obtainable, marker for worse short- and long-term outcomes after the procedure.European Heart Journal 03/2014; · 14.72 Impact Factor
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ABSTRACT: Postprocedural anticoagulation (AC) after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) may be administered for a number of specific therapeutic indications (e.g. atrial fibrillation or left ventricular thrombus). However, the safety and effectiveness of such post-PCI AC for specific indications are not well defined. Thus, we sought to study outcomes after postprocedural AC for specific indications in patients undergoing primary PCI for STEMI in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial. Patients who underwent primary PCI for STEMI in the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial were grouped according to whether they received specific indication AC. Adverse outcomes were assessed using propensity-adjusted multivariate analyses. After excluding patients who received post-PCI AC solely for routine prophylaxis, 410 patients (16.6%) received postprocedural AC for specific indications and 2,063 patients (83.4%) received no post-PCI AC. After propensity adjustment, use of postprocedural AC for specific indications was associated with higher rates of cardiac mortality, reinfarction, stent thrombosis, and major bleeding at 30 days compared with patients who received no AC post-PCI. In conclusion, in this large prospective study, use of postprocedural AC for specific indications after primary PCI for STEMI was independently associated with early rates of adverse ischemic and hemorrhagic outcomes. Post-PCI AC for specific indications was also associated with worse outcomes from 30 days to 3 years. Further studies are warranted to determine the optimal use of postprocedural AC after primary PCI in STEMI.The American Journal of Cardiology 08/2014; · 3.21 Impact Factor