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 - 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
UR - https://www.scopus.com/pages/publications/85082864609
UR - https://www.scopus.com/pages/publications/85082864609#tab=citedBy
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 -