AT THE 2018 CRT MEETING
WASHINGTON (FRONTLINE MEDICAL NEWS) – When paraplegics and quadriplegics have an acute MI and are candidates for revascularization, they should be treated preferentially with a percutaneous coronary intervention, according to data presented at the 2018 Cardiovascular Research Technologies meeting.
When compared 30 days after revascularization, the rates of major adverse cardiovascular events (MACE) following coronary artery bypass grafting (CABG) were 22% in the group with paraplegia or quadriplegia versus only 3.5% in those without loss of limb function. For percutaneous coronary intervention (PCI), the rates were 6% versus 2%, respectively, reported Xuming Dai, MD, PhD, an interventional cardiologist and assistant professor at the University of North Carolina at Chapel Hill.
A study of revascularization outcomes in patients with paraplegia or quadriplegia was undertaken after Dr. Dai was faced with two such patients, of whom one was ultimately referred for CABG. Concerned at the time about the suitability of CABG for patients with the potential for risk factors different from ambulatory patients, Dr. Dai consulted the literature.
“There are no guidelines, no studies. I could not even find a case report,” Dr. Dai recounted.
As a result, he initiated his own study, looking for such cases in the New York State Inpatient Database, in which there were 1,400 patients with paraplegia or quadriplegia and more than 400,000 without these limb impairments who had presented with acute MI over the period of study. After comparing outcomes in these two groups, a subsequent analysis was performed in which each patient with paraplegia/quadriplegia was matched by propensity scoring to five patients from the database without paraplegia/quadriplegia.
Notably, patients with paraplegia/quadriplegia were found to represent a small but steady proportion of acute MI cases. With only modest variation, the rate hovered around 0.2%-0.3% of cases per year.
“The patients with paraplegia or quadriplegia tended to be somewhat younger [67 vs. 70 years of age; P less than .001], have more comorbidities, and were more likely to be enrolled in Medicare,” Dr. Dai reported.
Of patients in the database without paraplegia/quadriplegia, 56% received medical therapy alone and 14% underwent catheterization but were not revascularized. Of the 31% who were revascularized, 82% underwent PCI, and the remainder underwent CABG.
Among those with paraplegia/quadriplegia, 83.7% were managed medically and 7.2% underwent catheterization but no revascularization. Of the 9.1% who were revascularized, 7.2% underwent PCI and 1.9% underwent CABG.
When evaluated with propensity scoring, the differences in outcomes between those with or without paraplegia/quadriplegia were more modest, but MACE rates after CABG remained significantly higher (8.4% vs. 3.5%; P = .02). In contrast, the difference in MACE rates after propensity matching was no longer significantly higher in the paraplegia/quadriplegia group treated with PCI (4.4% vs. 2.0%; P = .46).
When CABG was compared to PCI among those with paraplegia/quadriplegia, the rate of in-hospital mortality was almost four times higher (9.5% vs. 2.5; P less than.01). Paraplegic/quadriplegic patients treated with CABG also had longer lengths of hospital stay and incurred higher treatment costs, according to Dr. Dai.
The moderator of the session at which these data were presented, Scott Schurmer, MD , chief of cardiology at Texas Tech Health Sciences Center, Lubbock, cautioned about the limitations of propensity scoring. He also suggested that PCI, based on concern for potential comorbidities in patients with paraplegia and quadriplegia, would likely be the choice of many physicians even without these data.
Dr. Dai reported no financial relationships to disclose.
SOURCE: Dai X. CRT 2018.