Without Preprocedural Aspirin, PCI Carries Higher Risk of In-Hospital Death, Stroke

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Despite guideline recommendations to the contrary, a substantial segment of patients undergoing percutaneous coronary intervention (PCI) fail to receive preprocedural aspirin. Such patients experience higher risk of in-hospital death and stroke, according to findings to be presented in a moderated poster session at the American College of Cardiology Annual Scientific Session on March 11, 2013.

Mohamad Kenaan, MD, and colleagues at the University of Michigan Health Systems (Ann Arbor, MI), analyzed data from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium Percutaneous Coronary Intervention (BMC2 PCI) registry on 65,175 PCI patients treated at 42 hospitals in Michigan from 2010 to 2011.

Within that population, 4,640 patients (7.1%) did not receive aspirin within 24 hours prior to PCI. Only 495 patients (10.7%) within this group had a documented contraindication. The most common diagnosis in the non-aspirin group was NSTEMI/unstable angina (40%), followed by stable CAD (31%), STEMI (18%), and other (11%). Patients not given aspirin were more likely to have a history of GI bleeding and to present with STEMI, in cardiogenic shock, or after cardiac arrest than those who received the drug. They were less likely to have had previous PCI.

Rates of multiple in-hospital outcomes were higher for patients not given aspirin (table 1).

Table 1. Unadjusted In-Hospital Outcomes

 

No Aspirin

Aspirin

P Value

Death

3.9%

1.2%

< 0.001

Transfusion

5.3%

3.3%

< 0.001

Stroke

0.5%

0.2%

0.02

Need for CABG

1.5%

0.9%

< 0.001

Contrast-Induced Nephropathy

4.0%

2.5%

< 0.001

Nephropathy Requiring Dialysis

0.5%

0.2%

0.005

 

After propensity score adjustment, however, the lack of aspirin was only associated with increased risk of death (3.87% vs. 2.79%; OR 1.89; 95% CI 1.32-2.71; P = 0.005) and stroke (0.52% vs. 0.15%; OR 4.24; 95% CI, 1.49-12.11; P = 0.007). There was no difference in bleeding, need for transfusion, or contrast-induced nephropathy.

The relationship between aspirin and mortality was evident across multiple subgroups; one exception was patients presenting in cardiogenic shock, who experienced no added risk without aspirin therapy.

Aspirin Should Not Be Taken for Granted

In a telephone interview with TCTMD, study coauthor Hitinder S. Gurm, MD, of the University of Michigan Medical Center (Ann Arbor, MI), said, “The thing that shocked us was that 7% of patients were not on aspirin prior to PCI. This is a very large number, especially if [you consider that] we’re looking at the entire population of patients getting PCI in Michigan. . . . My guess is that if we were to look across the country, we would find the same thing.” A nationwide study is the next step, he added.

“We’ve been using aspirin for a long time, and I think what’s happening is that it’s such a low- tech thing in some sense that we may be missing out on it. There’s not enough attention paid to it,” Dr. Gurm commented. Aspirin allergy is very rare in the PCI population, he said, and a history of GI bleeding can be dealt with using proton pump inhibitors and other approaches.

Based on the current findings, it can no longer be assumed that all PCI patients will receive aspirin as required, Dr. Gurm concluded. “We need to have a system to check that the patient got aspirin. . . . This is a very simple quality check that every hospital should introduce.”

Source:

Kenaan M. Lack of aspirin use prior to PCI is relatively common and strongly associated with increased in-hospital mortality. Presented at: American College of Cardiology Annual Scientific Session. March 11, 2013; San Francisco, CA.

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Disclosures
  • Dr. Kenaan reports no relevant conflicts of interest.
  • Dr. Gurm reports receiving research funding from the Agency of Healthcare Research and Quality, Blue Cross Blue Shield of Michigan, and the National Institutes of Health.

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