Acute MI Patients With Paraplegia Rarely Get Revascularization, Face Higher Risk of Death
New research raises concerns that spinal cord injury survivors, who now live decades longer than they used to, are not being offered cath and PCI.
WASHINGTON, DC—In what may be the first data of its kind, investigators of a new, retrospective study say that paraplegic patients with acute MI do well when treated with PCI, but most may not be offered the therapy.
Spinal cord injuries are most commonly seen in young adults, with an average age of 31. But as Xuming Dai, MD (NewYork-Presbyterian, Flushing, NY), said here at CRT 2018, people with different degrees of paralysis are living longer than ever before, often three decades or more beyond their original injury. Moreover, their coronary disease risk factors differ from those of the able bodied, with physical inactivity, fluctuation of BP due to autonomic dysreflexia, difficulties in glucose control, dyslipidemia, tobacco use, stress, and inflammation, particularly due to chronic urinary tract infections, all playing a larger role.
“Acute spinal injury management is so much better now--the rehab and also the support teams for these patients are really good,” Dai told TCTMD. “So paraplegic patients are living 30 years and more in wheelchairs, they're participating in sports, and they’re doing all kinds of things. Even quadriplegic patients are living 20 or 30 years.”
With greater longevity, acute MI in these patients is increasingly common, and best practices for how to treat it have not been established.
Two recent experiences drove this point home for Dai and colleagues: one a 74-year-old man with quadriplegia confined to bed rest for 20 years, another a 77-year-old man with paraplegia, wheelchair-bound for 38 years. Both presented with high-risk NSTEMI; one was treated with PCI and the other with CABG. The patient who underwent PCI was discharged 5 days later. The CABG-treated patient went into cardiac arrest post-op, spent 30 days in the ICU, and ultimately was transferred to a care facility.
New York Data
To get a better idea of the number of spinal cord injury survivors presenting with acute MI as well as their management and outcomes, Dai and colleagues reviewed MI admissions in the New York State Inpatient Database, ultimately identifying 1,400 paraplegic patients out of 402,569 admitted with acute MI. Compared to able-bodied patients, patients with paraplegia were younger (mean, 67.8 vs 70.7 years) and more likely to be black (16% vs 12%). They were also more likely to have hypertension, anemia, heart failure, and depression but less likely to have diabetes, hyperlipidemia, obesity, chronic lung disease, and renal impairment.
In terms of treatment, paraplegia patients were most commonly treated with medical therapy without diagnostic cath (83.7% vs 55.5% of able-bodied patients, P < 0.001). An additional 7.2% received catheterization only, 7.1% were treated with PCI, and 1.9% received CABG—all significantly lower than able-bodied acute MI patients.
Even after propensity matching, paraplegic patients were significantly more likely to get medical therapy without catheterization and less likely to get PCI or CABG.
In further analyses, Dai and colleagues found higher in-hospital mortality among patients with versus without paraplegia (22.4% vs 16.8% after propensity matching; P < 0.001). The lowest mortality was seen among patients who received PCI (1.7%), while CABG was associated with mortality rates almost on par with the medical therapy/no diagnostic cath group (22.2% and 24.6%, respectively). Not surprisingly, hospital costs were also significantly higher among paraplegic patients treated with CABG compared with those treated with PCI (mean, $231,323 vs $144,449).
“From this data, it’s pretty clear that PCI is very safe,” Dai told TCTMD. “The patients who went for PCI have the same outcomes as able-bodied patients.”
It’s not possible to tell from the retrospective administrative data how many patients may have been eligible but turned down treatment, he added. “If those patients are eligible, we should be a little more aggressive, since this is a treatment that’s known to be of benefit. And if we now find that paraplegics are not being offered cath and PCI, then we are undertreating them.”
Many of these paraplegic patients are presenting with very advanced multivessel disease but without typical symptoms, in large part because of inactivity, Dai observed. Quite often, he told TCTMD, MI and multivessel disease are being picked up when paraplegic patients are being worked up for other surgeries and procedures, or monitored in their wake, and not because of chest pain.
Following Dai’s presentation, session moderator Mohamed Effat, MD (University of Cincinnati, Mason, OH), pointed out that most interventional cardiologists would already have presumed that PCI would be the best approach. As such, he asked, what does this review add?
“First, I would say we now have a study showing CABG is not really a good idea, which all of us interventional cardiologists would probably agree,” Dai replied. “But surgeons have different views on multivessel disease, even in paraplegia, and they’re very strongly [pushing] to take these patients to the OR.”
Data from this series would strongly favor PCI over CABG when revascularization is an option, he continued. What’s more, Dai said, “there’s no difference in safety and outcomes between able-bodied and paraplegic patients, so I think we can be a little more aggressive about cathing these patients.”
To TCTMD, Effat called the series “interesting and important.”
“At the University of Cincinnati Medical Center, we occasionally see patients with hemiplegia and paraplegia presenting with AMI; our practice has been to provide PCI unless prohibited by clear contraindications—similar to nonparaplegic cases,” Effat told TCTMD in an email. “However, due to a variety of concerns, some cardiologists may be hesitant to aggressively proceed with PCI in the paraplegic patient, but this case highlights the value of pursuing this approach, versus being conservative.”
Dai, X. Acute myocardial infarction in patients with paraplegia: percutaneous coronary intervention or coronary artery bypass grafting? Presented at: CRT 2018. March 4, 2018. Washington, DC.
- Dai reports no relevant conflicts of interest.