PCI-Related Stroke Rate Exceedingly Low but Linked to Poor Prognosis

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While the incidence of stroke during percutaneous coronary intervention (PCI) is low, outcomes in those with the complication are poor, according to a study published online July 30, 2013, ahead of print in Circulation: Cardiovascular Interventions. The authors add that improving results for patients with in-hospital stroke is difficult as most predictors are not modifiable.

Researchers led by Uwe Zeymer, MD, of Herzzentrum Ludwigshafen (Ludwigshafen, Germany), looked at 46,888 patients undergoing elective PCI (n = 22,783) or emergency PCI for ACS (n = 24,105) at 176 institutions in 33 European countries. All patients were enrolled in the Euro Heart Survey PCI Registry and treated from May 2005 to April 2008.

Mortality, Morbidity High After Stroke

Only 0.4% of all patients developed an in-hospital stroke. Not surprisingly, the rate was higher for those receiving PCI for ACS compared with those undergoing elective PCI (0.6% vs. 0.3%; P < 0.001).

In-hospital mortality among patients with stroke was substantially higher than in patients without stroke after PCI for ACS. Rates of MACE, MI, renal failure requiring dialysis, intracranial bleeding, and major bleeding followed the same pattern (table 1). Median hospital length of stay was longer for patients with stroke compared with those without stroke (7 vs. 3 days; P < 0.01) after PCI for ACS.

Table 1. Cumulative In-Hospital Outcomes of PCI for ACS

 

P < 0.01 for all.

On multivariate analysis, independent predictors of stroke during PCI for ACS were:

• Hemodynamic instability
• Age ≥ 75 years
• History of stroke
• Congestive heart failure

Prior CABG was associated with a lower risk of stroke.

Outcomes for elective PCI patients were similar to those undergoing PCI for ACS. However, overall complications were inherently lower due to the lower-risk nature of the procedure (table 2). Median hospital length of stay was longer for patients with stroke compared with those without (2 vs. 1 days; P < 0.01) after elective PCI.

Table 2. Cumulative In-Hospital Outcomes of Elective PCI

 

P < 0.01 for all.

PCI of a bypass graft and renal failure were found to be the only independent predictors of stroke in elective PCIs.

Independent Predictors Not Modifiable

Explanations for the higher stroke rate in PCI for ACS patients could include “a more severe vascular calcification in patients presenting with an ACS and a longer duration of the catheterization procedure during urgent or even emergency situations with possibly less careful advancement of catheters through the aorta under pressure of time,” according to Dr. Zeymer and colleagues.

In addition, they say, cerebrovascular events “occur in a distinct group of patients undergoing PCI. The higher the patient’s atherosclerotic and vascular risk, the higher the patient’s risk for periprocedural stroke, in general.”

With regard to the “remarkable difference” in independent predictors of stroke seen between the PCI for ACS and elective PCI groups, the authors suggest severity of vascular calcification, which could be lower in elective procedures, as a likely explanation.

Nevertheless, “most of the risk factors associated with periprocedural stroke are not modifiable before PCI,” they write. “Therefore, an improvement of the prognosis of patients undergoing this complication will only be possible by improving therapeutic options of cerebrovascular accidents.”

Dr. Zeymer and colleagues recommend that a set of guidelines be developed for treating this complication. Additionally, “it will be of paramount importance to develop studies evaluating best medical and interventional treatment after this complication . . . to reduce the high mortality and morbidity associated with this complication in the future,” they conclude.

Study Details

Patients who developed stroke after PCI for ACS were older, more likely female, and more likely to have a history of valvular heart disease or stroke. The use of statins was less frequent in patients with stroke after PCI, whereas cardiovascular risk factors like arterial hypertension, diabetes, and hypercholesterolemia did not differ between groups. Patients with stroke more often presented with STEMI and had worse left ventricular function on admission compared with patients without stroke.

 

Source:

Werner N, Bauer T, Hochadel M, et al. Incidence and clinical impact of stroke complicating percutaneous coronary intervention: Results of the Euro heart survey percutaneous coronary interventions registry. Circ Cardiovasc Interv. 2013;Epub ahead of print.

 

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