Can modern stroke interventional techniques improve patient outcomes?
Strokes occurring after percutaneous coronary intervention (PCI) have become a worrisome trend, according to U.S. data.
From 2003 to 2016, adjusted stroke rates were on the upswing following PCI for all indications (P<0.001 for all):
- ST-segment elevation MI (STEMI): from 0.6% to 0.96%
- Non-ST-segment elevation MI (NSTEMI): from 0.5% to 0.6%
- Unstable angina or stable ischemic disease: from 0.3% to 0.72%
What's more, these trends persisted after including only patients who got PCI within 48 hours of admission and excluding PCIs at low-volume centers, reported a team led by Mohamad Alkhouli, MD, of West Virginia University in Morgantown. Their study was published in JACC: Cardiovascular Interventions.
The strongest predictors of stroke were carotid disease, cardiogenic shock, atrial fibrillation, and older age -- all of which increased significantly over time as well.
"Acute ischemic stroke after PCI is increasing over time, partially because of the increasing burden of comorbidities among patients undergoing PCI and the increasing complexity of PCI procedures themselves," Alkhouli and colleagues suggested.
More work is needed to assess the factors contributing to this pattern and ways to prevent such strokes, they acknowledged. "Although several of the predictors of post-PCI stroke in our study are not modifiable, their recognition is essential for comprehensive risk stratification of patients referred for PCI."
Notably, use of thrombolytics, cerebral angiography, and mechanical thrombectomy increased over time but remained infrequent (4.56%, 4.73%, and 0.65%, respectively).
"Patients who experience post-PCI strokes during hospitalization are, in theory, in an ideal setting for prompt recognition and management of the stroke. This includes the use of thrombolytic agents and/or early referral for cerebral angiography with or without mechanical thrombectomy if anatomically suitable," the investigators said.
"However, several unique aspects of post-PCI ischemic stroke should be acknowledged. First, thrombolysis would have a very limited effect if dislodged debris consisted of atheromatous materials and not thrombus," cautioned Ahmed Abdel-Latif, MD, PhD, and Naoki Misumida, MD, both of the University of Kentucky, Lexington, in an accompanying editorial.
Furthermore, bleeding is already a concern with anticoagulation use and femoral access during PCI, they noted.
The study was based on more than 8.7 million patients who were listed as having received PCI in 2003-2016 by the National Inpatient Sample, an all-payer administrative claims-based database.
The overall incidence of post-PCI ischemic stroke was 0.56% during the observation period. High-volume hospitals were significantly less likely to have PCIs followed by stroke.
Not surprisingly, patients with post-PCI stroke were more likely to die in-hospital. Such strokes were also associated with more than double the length of hospital stay, more than triple the increase in non-home discharges, and more than 60% increase in costs.
"Although the overall incidence of ischemic stroke seems to be declining with the advancement of prevention strategies, PCI-related stroke is paradoxically increasing, warranting further investigation of this rare, but potentially devastating, complication," commented Abdel-Latif and Misumida.
The 0.56% stroke incidence in this study may be "somewhat overestimated," however, as it has ranged from 0.10% to 0.34% in other PCI registries, according to them. "This may be due to coding errors or potential inclusion of admissions that initially presented with stroke and subsequently required PCI during hospitalization."
Nevertheless, the observed trends are concerning and warrant further investigation, they wrote.
Study authors acknowledged that their database lacked certain technical and procedural factors, such as access site, PCI target, and intra- and post-procedural medications. There were also no CT results or disability scores to help ascertain stroke diagnosis.
Abdel-Latif and Misumida suggested that shifting PCI techniques may have something to do with the increase in post-stenting strokes.
"First, radial access, especially right radial approach, can theoretically increase stroke risk due to increased wire and catheter manipulations especially with challenging brachiocephalic and coronary anatomy," according to them.
"However, a meta-analysis of 36 studies showed no statistically significant difference in the rate of stroke between radial and femoral access in the randomized trials subset (13 trials) and even a lower rate of stroke in the radial group in observational studies," they continued. "Thus, wider adoption of radial access in contemporary practice does not explain the increasing trend of post-PCI stroke."
Other possibilities are mechanical circulatory support and atherectomy use, which were indeed among the weaker predictors of post-PCI stroke that Alkhouli's group found.
"The study calls for more innovative approaches for the prevention of post-PCI stroke which has dismal prognosis," wrote Abdel-Latif and Misumida.
Alkhouli and Misumida disclosed no relevant conflicts of interest.
Abdel-Latif disclosed support from institutional and NIH grants.
JACC: Cardiovascular Interventions
Source Reference: Alkhouli M, et al "Incidence, predictors, and outcomes of acute ischemic stroke following percutaneous coronary intervention" JACC Cardiovasc Interv 2019; DOI: 10.1016/j.jcin.2019.04.015.
JACC: Cardiovascular Interventions
Source Reference: Abdel-Latif A, Misumida N "Ischemic stroke after percutaneous coronary intervention: rare, but devastating" JACC Cardiovasc Interv 2019; DOI: 10.1016/j.jcin.2019.05.013.
Read the original article on Medpage Today: Post-PCI Strokes Heading in the Wrong Direction