TY - JOUR
T1 - Incidence and Outcomes of Acute Coronary Syndrome After Transcatheter Aortic Valve Replacement
AU - Mentias, Amgad
AU - Desai, Milind Y.
AU - Saad, Marwan
AU - Horwitz, Phillip A.
AU - Rossen, James D.
AU - Panaich, Sidakpal
AU - Elbadawi, Ayman
AU - Abbott, J. Dawn
AU - Sorajja, Paul
AU - Jneid, Hani
AU - Tuzcu, E. Murat
AU - Kapadia, Samir
AU - Vaughan-Sarrazin, Mary
N1 - Funding Information:
Dr. Mentias has received support from National Institutes of Health NRSA institutional grant (T32 HL007121) to the Abboud Cardiovascular Research Center. Dr. Sarrazin is supported by funding from the National Institute on Aging (R01AG055663-01); and by the Health Services Research and Development Service of the Department of Veterans Affairs. Dr. Horwitz has received grant support from Edwards Lifesciences and Boston Scientific. Dr. Sorajja has received grant support from Edwards Lifesciences, Boston Scientific, Medtronic, and Abbott Structural; and consulting fees from Edwards Lifesciences, Boston Scientific, Medtronic, Abbott Structural, W.L. Gore, Admedus, and Cardionomics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Publisher Copyright:
© 2020 American College of Cardiology Foundation
PY - 2020/4/27
Y1 - 2020/4/27
N2 - Objectives: This study sought to address a knowledge gap by examining the incidence, timing, and predictors of acute coronary syndrome (ACS) after transcatheter aortic valve replacement (TAVR) in Medicare beneficiaries. Background: Evidence about incidence and outcomes of ACS after TAVR is scarce. Methods: We identified Medicare patients who underwent TAVR from 2012 to 2017 and were admitted with ACS during follow-up. We compared outcomes based on the type of ACS: ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. In patients with non–ST-segment elevation ACS, we compared outcomes based on the treatment strategy (invasive vs. conservative) using inverse probability weighting analysis. Results: Out of 142,845 patients with TAVR, 6,741 patients (4.7%) were admitted with ACS after a median time of 297 days (interquartile range: 85 to 662 days), with 48% of admissions occurring within 6 months. The most common presentation was NSTEMI. Predictors of ACS were history of coronary artery disease, prior revascularization, diabetes, valve-in-TAVR, and acute kidney injury. STEMI was associated with higher 30-day and 1-year mortality compared with NSTEMI (31.4% vs. 15.5% and 51.2% vs. 41.3%, respectively; p < 0.01). Overall, 30.3% of patients with non–ST-segment elevation ACS were treated with invasive approach. On inverse probability weighting analysis, invasive approach was associated with lower adjusted long-term mortality (adjusted hazard ratio: 0.69; 95% confidence interval: 0.66 to 0.73; p < 0.01) and higher risk of repeat revascularization (adjusted hazard ratio: 1.29; 95% confidence interval: 1.16 to 1.43; p < 0.001). Conclusions: After TAVR, ACS is infrequent (<5%), and the most common presentation is NSTEMI. Occurrence of STEMI after TAVR is associated with a high mortality with nearly one-third of patients dying within 30 days. Optimization of care is needed for post-TAVR ACS patients and if feasible, invasive approach should be considered in these high-risk patients.
AB - Objectives: This study sought to address a knowledge gap by examining the incidence, timing, and predictors of acute coronary syndrome (ACS) after transcatheter aortic valve replacement (TAVR) in Medicare beneficiaries. Background: Evidence about incidence and outcomes of ACS after TAVR is scarce. Methods: We identified Medicare patients who underwent TAVR from 2012 to 2017 and were admitted with ACS during follow-up. We compared outcomes based on the type of ACS: ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. In patients with non–ST-segment elevation ACS, we compared outcomes based on the treatment strategy (invasive vs. conservative) using inverse probability weighting analysis. Results: Out of 142,845 patients with TAVR, 6,741 patients (4.7%) were admitted with ACS after a median time of 297 days (interquartile range: 85 to 662 days), with 48% of admissions occurring within 6 months. The most common presentation was NSTEMI. Predictors of ACS were history of coronary artery disease, prior revascularization, diabetes, valve-in-TAVR, and acute kidney injury. STEMI was associated with higher 30-day and 1-year mortality compared with NSTEMI (31.4% vs. 15.5% and 51.2% vs. 41.3%, respectively; p < 0.01). Overall, 30.3% of patients with non–ST-segment elevation ACS were treated with invasive approach. On inverse probability weighting analysis, invasive approach was associated with lower adjusted long-term mortality (adjusted hazard ratio: 0.69; 95% confidence interval: 0.66 to 0.73; p < 0.01) and higher risk of repeat revascularization (adjusted hazard ratio: 1.29; 95% confidence interval: 1.16 to 1.43; p < 0.001). Conclusions: After TAVR, ACS is infrequent (<5%), and the most common presentation is NSTEMI. Occurrence of STEMI after TAVR is associated with a high mortality with nearly one-third of patients dying within 30 days. Optimization of care is needed for post-TAVR ACS patients and if feasible, invasive approach should be considered in these high-risk patients.
KW - acute coronary syndrome
KW - percutaneous coronary intervention
KW - transcatheter aortic valve replacement
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U2 - 10.1016/j.jcin.2019.11.027
DO - 10.1016/j.jcin.2019.11.027
M3 - Article
C2 - 32061612
AN - SCOPUS:85082864609
SN - 1936-8798
VL - 13
SP - 938
EP - 950
JO - JACC: Cardiovascular Interventions
JF - JACC: Cardiovascular Interventions
IS - 8
ER -