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Acute Coronary Syndrome After TAVR
Study Questions:
What is the incidence, clinical characteristics, and prognosis of acute coronary syndromes (ACS) following transcatheter aortic valve replacement (TAVR)?
Methods:
Consecutive patients undergoing TAVR at a single Canadian center between May 2007 and November 2017 were included in this observational analysis. Those who did not survive index TAVR hospitalization or did not have a minimum follow-up of 6 months were excluded. Universal Definition of Myocardial Infarction was used for ACS identification on follow-up.
Results:
A total of 779 patients with a mean Society of Thoracic Surgeons (STS) score of 6.8 were included. Mean age was 79 ± 9 years, 52% were male, and 68% had coronary artery disease (CAD) at the time of TAVR. At a median follow-up of 25 months, 10% (78/ 779) presented with ≥1 ACS event with 50% of the events occurring in the first year following TAVR. Male sex (hazard ratio [HR], 2.19; 95% confidence interval [CI], 1.36-3.54), prior CAD (HR, 2.78; 95% CI, 1.50-5.1), and nontransfemoral TAVR approach (HR, 1.71; 95% CI, 1.04-2.75) independently predicted ACS following TAVR. Most common ACS clinical syndromes were type 2 non–ST-segment elevation myocardial infarction (NSTEMI) (35.9%), unstable angina (34.6%), type 1 NSTEMI (28.2%), and STEMI (1.3%). Coronary angiography was performed in 53/78 (67.9%) patients with ACS, and 30/78 (56.6%) received percutaneous coronary intervention. Incidence of in-hospital heart failure and acute kidney injury was 24.4%. Three patients (3.8%) died during the in-hospital phase. In-hospital mortality at the time of ACS was 3.8%. Overall, the rate of MACCE (all-cause death, MI, new revascularization, or stroke) after the first ACS episode was 46.7%.
Conclusions:
Approximately 10% of patients undergoing TAVR in this cohort were readmitted with ACS at a median follow-up of 25 months. Male sex, prior CAD, and nontransfemoral approach independently predicted ACS occurrence.
Perspective:
This analysis highlights the high risk of ACS and medium-term mortality in elderly patients receiving TAVR. Nontransfemoral approach is a marker of high peripheral vascular disease burden, thereby increasing ACS risk in follow-up. As TAVR becomes increasingly popular in younger lower-risk patients, future studies will inform ACS risk in such patients.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Acute Kidney Injury, Angina, Unstable, Cardiac Surgical Procedures, Coronary Angiography, Coronary Artery Disease, Geriatrics, Heart Failure, Heart Valve Diseases, Hospital Mortality, Myocardial Infarction, Percutaneous Coronary Intervention, Stroke, Transcatheter Aortic Valve Replacement
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