Post-PCI Neurological Events, Though Infrequent, Continue to Carry ‘Abysmal’ Consequences

Rates of cerebrovascular accident (CVA) or TIA after PCI have remained low since 2002, despite increases in several risk factors for stroke, a retrospective study shows. Nonetheless, in-hospital and 1-year mortality are still substantially higher in patients with neurologic events.

“The outcomes of such patients remain abysmal … despite advances in the overall safety and efficacy of PCI,” Ron Waksman, MD, of MedStar Washington Hospital Center (Washington, DC), and colleagues write in their American Heart Journal paper, published online November 10, 2015. “Further research is required to facilitate earlier diagnosis of CVA, and the relative utility of thrombolytics versus mechanical thrombectomy remains largely unexplored.”

The investigators looked at data on 25,626 patients (mean age 65 years; 65.2% men) who underwent PCI at their center from January 2002 to June 2015. During that time there were 110 neurologic events during or within 24 hours after PCI (0.43%), including 86 CVAs (mostly ischemic) and 24 TIAs.

Incidence of CVA/TIA remained stable over time despite increases in certain risk factors at baseline, including age, MI, insulin-dependent diabetes, chronic renal insufficiency, and proportion of type C lesions. Hypercholesterolemia, in contrast, became less frequent over time.

In the hospital, patients with vs without neurologic events had higher rates of bleeding, MI, acute renal failure, and vascular complications after PCI, and the median hospital stay was longer (9.5 vs 2 days; P < .001). Furthermore, having a CVA/TIA was associated with higher rates of dying in the hospital (20.7% vs 1.5%) and at 1 year (45.0% vs 7.3%; P < .001 for both). Mortality rates were substantially lower following TIA compared with stroke, however.

Waksman and colleagues say the findings are “reasonably consistent” with prior studies, and they offer a couple reasons to explain why the risk of neurologic events remained low in spite of the increasing level of risk among treated patients.

First, guiding catheters have become smaller, possibly offsetting the increase in patient risk, they say. “It might also be explained by an overall improvement in medical therapy,” they add. “More specifically, high-dose statin therapy and more potent antiplatelet therapy may stabilize plaques in the aorta that would otherwise be a potential nidus for thromboembolism formation.”

Room for Improvement

Multiple factors were independently associated with the development of neurologic events: previous CVA (OR 2.4; 95% CI 1.4-4.4), African-American race (OR 2.4; 95% CI 1.5-3.9), and use of intra-aortic balloon pumps (IABPs; OR 4.9; 95% CI 2.7-8.8).

The latter relationship “could potentially be explained by the prevalence of hemodynamic instability in patients who might have a history of CVA or higher incidence of carotid disease, but it is also reasonable to speculate that an IABP might increase the risk of CVA by embolization of complex aortic atheromas,” according to Waksman and colleagues.

They conclude that even though neurologic outcomes remain rare after PCI, their strong association with poorer clinical outcomes “emphasizes the need for effective treatment of stroke after PCI. Decreasing the time of diagnosis by performing cerebral magnetic resonance imaging as soon as possible after symptom onset would of course be beneficial. And if an ischemic stroke is diagnosed, use of intravenous thrombolytic therapy or mechanical thrombectomy for timely cerebral reperfusion could be one way to reduce both morbidity and mortality.

Source: 
Didier R, Gaglia MA Jr, Koifman E, et al. Cerebrovascular accidents after percutaneous coronary interventions from 2002 to 2014: incidence, outcomes, and associated variables. Am Heart J. 2015;Epub ahead of print.

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