Percutaneous coronary intervention in the polyvascular patient remains a high-risk procedure

From the large National Inpatient Sample, Bashar et al. quantitatively prove an anticipated result. Patients undergoing percutaneous coronary intervention (PCI) with documented extracardiac vascular disease (ECVD) have increased risk of in-hospital death, major adverse cerebral and cardiovascular events (MACCE), acute ischemic stroke, and major bleeding. Peripheral arterial disease (PAD) patients undergoing PCI have 4.9% in-hospital mortality compared to 2.7% in those without ECVD. Similarly, patients with documented cerebrovascular disease have a 2.5% risk of in-hospital acute ischemic stroke compared to 0.9% in those without ECVD. PAD patients have 2.9% in-hospital major bleeding compared to 1.5% in the no ECVD group. Adjusting for the increased burden of comorbidities in those with PAD demonstrates an adjusted odds ratio of 1.48 (95% confidence interval 1.40–1.56) for mortality. The adjusted odds ratio is 2.79 (2.67–2.91) for acute ischemic stroke in those with cerebrovascular disease compared to no ECVD. Explanatory comorbidities most differentially elevated in PCI patients with ECVD are diabetes, chronic kidney disease, and heart failure. While no cardiovascular clinician will be surprised by these findings, the value is detailed quantitative documentation with highly representative data reflecting contemporary practice.

The summary message; PAD patients undergoing PCI have double the risk of in-hospital mortality and major bleeding compared to no ECVD patients. Patients with documented cerebrovascular disease have at least a doubling of acute ischemic stroke risk with PCI.

What are the clinical implications? In the chronic coronary syndrome patient, the presence of significant ECVD might prompt a less invasive management strategy, particularly in the presence of diabetes, chronic kidney disease, and heart failure. In the acute coronary syndrome patient where PCI is often the best approach, the presence of ECVD warrants consideration of risk mitigation strategies as timing permits. These include preloading with more rapidly acting antiplatelet agents such as ticagrelor and prasugrel or cangrelor in the acute setting, even more meticulous access such as ultrasound-guided particularly when transfemoral, periprocedural glycemic control, heart failure control, minimizing contrast load, and more gently navigating the brachiocephalic vessels and aortic arch.

The increased long-term hazards of mortality and MACCE in patients undergoing PCI or coronary artery bypass surgery with ECVD are well documented in prior studies.^1,2 Post discharge, even more critical attention should be given to long-term risk reduction strategies in these polyvascular patients.³ Tobacco cessation, optimal antiplatelet regimen and duration (PAD increases DAPT Score), optimal weight, diabetes and lipid control. Consideration of PCSK9 in statin failures, including perhaps inclisiran in those challenged with daily medication compliance.⁴ In person and telehealth cardiac rehabilitation programs have demonstrated benefit.⁵ Finally, the ECVD itself should be appropriately evaluated with careful consideration of optimal timing after PCI depending on symptom status and noninvasive findings. Identification and optimal treatment of ECVD likely places patients at lower risk in the eventuality of needing coronary revascularization.

By quantifying the incremental risk of adverse in-hospital outcomes in PCI patients with ECVD, Bashar et al. reinforce the importance of the cardiovascular community in diagnosing, considering, and appropriately treating all vascular diseases and aggressive risk factor therapies.