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Trends in Post-PCI Acute Ischemic Stroke
Study Questions:
What are the temporal trends in the incidence of ischemic stroke among patients undergoing percutaneous coronary intervention (PCI), the predictors of post-PCI ischemic stroke, and the impact of post-PCI ischemic stroke on in-hospital morbidity, mortality, length of stay, and cost?
Methods:
The investigators used the National Inpatient Sample to identify patients who underwent PCI between January 1, 2003, and December 31, 2016. The incidence of post-PCI ischemic stroke was calculated, and its predictors were assessed. In-hospital outcomes of patients with and those without post-PCI stroke were also compared. The statistical significance of the trend in the incidence was assessed using the Cochrane-Armitage test. To reduce the effect of selection bias, a propensity score matching model was developed using logistic regression to derive two matched groups for comparative outcomes analysis.
Results:
The adjusted incidence of post-PCI ischemic stroke increased during the study period from 0.6% to 0.96% following PCI for ST-segment elevation myocardial infarction (STEMI), from 0.5% to 0.6% following PCI for non–STEMI (NSTEMI), and from 0.3% to 0.72% following PCI for unstable angina or stable ischemic disease (ptrend < 0.001). Carotid disease, cardiogenic shock, atrial fibrillation, and older age were the strongest predictors of post-PCI ischemic stroke. Post-PCI stroke rates were lower at high-volume versus low- to intermediate-volume centers. Thrombolytics, cerebral angiography, and thrombectomy use increased over time but remained infrequent. After propensity score matching, in-hospital mortality was higher among patients with post-PCI stroke (23.5% vs. 11.0%, 9.5% vs. 2.8%, and 11.5% vs. 2.4% in the STEMI, NSTEMI, and unstable angina or stable ischemic heart disease cohorts, respectively; p < 0.001). Post-PCI stroke was associated with a >2-fold increase in length of stay, a >3-fold increase in nonhome discharges, and a >60% increase in cost.
Conclusions:
The authors concluded that the incidence of post-PCI ischemic stroke increased significantly over the past decade, partially because of the increasing complexity of patients undergoing PCI over time.
Perspective:
This analysis reports that the incidence of post-PCI ischemic stroke is low but has increased significantly over the past decade, partially because of the increasing complexity of the patients treated and the intricacy of the PCI techniques themselves. Carotid artery disease, cardiogenic shock, atrial fibrillation, older age, and low institutional annual PCI volume were the strongest predictors of post-PCI ischemic stroke. Additional studies are indicated to assess effective prevention and management strategies for post-PCI stroke, given its considerable persistent morbidity, mortality, resource use, and cost.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine
Keywords: Acute Coronary Syndrome, Angina, Unstable, Atrial Fibrillation, Brain Ischemia, Carotid Artery Diseases, Cerebral Angiography, Coronary Artery Disease, Fibrinolytic Agents, Hospital Mortality, Length of Stay, Myocardial Infarction, Percutaneous Coronary Intervention, Secondary Prevention, Shock, Cardiogenic, Stroke, Thrombectomy, Vascular Diseases
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