Increased inflammatory status associated with worse outcomes post PCI
Residual inflammatory risk and the impact on clinical outcomes in patients after percutaneous coronary interventions
Literature - Kalkman DN, Aquino M, Claessen BE et al. - Eur Heart J 2018; published online ahead of printIntroduction and methods
Residual inflammatory risk (RIR), defined as hsCRP >2 mg/L and LDL-c >70mg/dL, describes the inflammatory status in patients with known CVD [1-4]. The prevalence of persistent high RIR in patients undergoing percutaneous coronary interventions (PCI) is not well established and current guidelines do not recommend its assessment. Moreover, the association between RIR and clinical outcomes in post-PCI patients is not known.
This study assessed the prevalence of persistent high RIR in patients undergoing PCI, and evaluated the association with adverse clinical outcomes at one year after PCI. For this purpose, a retrospective analysis of a PCI registry (MountSinai Hospital,NY,USA) was conducted between 1 January 2009 and 31 December 2016. Patients with ≥2 serial hsCRP measurements within four weeks or more were stratified into four RIR groups:
- persistent high RIR: two high hsCRP values
- attenuated RIR: first hsCRP high, second hsCRP low
- increased RIR: first hsCRP low, second hsCRP high
- persistent low RIR: two low hsCRP values
The primary endpoint was one year all-cause death and the secondary endpoints were myocardial infarction (MI), target vessel revascularization, target lesion revascularization (TLR), bleeding, stent thrombosis, cerebrovascular accident (CVA), major adverse cardiovascular events (MACE), and MACE+. MACE was defined as the composite of all-cause death, MI, and stroke and MACE+ as the composite endpoint of all-cause death, MI, stroke, and any revascularization.
Main results
- Of 7026 patients, 38.0% had persistent high RIR, 10.0% had increased RIR, 15.0% had attenuated RIR, and 37.0% had persistent low RIR.
- The primary endpoint was observed in 2.6% of persistent high RIR, 1.0% of increased RIR, 0.3% of attenuated RIR, and 0.7% of persistent low RIR (P <0.01).
- MI was observed in 7.5%, 6.4%, 4.6%, and 4.3% of patients, respectively (P< 0.01).
- MACE occurred in 9.7% of persistent high RIR, 6.9% increased RIR, and 5.1% in both attenuated and persistent low RIR (P< 0.01), and MACE+ was observed in 26.1%, 22.5%, 24.2% and 21.4% of patients, respectively (P<0.01).
- After multivariable adjustment, the persistent high RIR group had an HR of 3.2 for one year all-cause death (95%CI: 1.72–6.02; P<0.01), and an HR of 1.6 for one year MI (95%CI: 1.23–2.08; P<0.01), compared to the persistent low RIR group.
- After multivariable adjustment, the HR for TLR was 1.25 (95%CI: 1.06-1.49, P<0.001), for MACE 1.72 (95%CI: 1.36-2.18, P<0.001) and for MACE+ 1.21 (95%CI: 1.07-1.38, P<0.001) in the persistent high RIR group as compared with the persistent low RIR group.
Conclusion
A high percentage of patients undergoing PCI have persistent high RIR, which results in a higher one year rate of all-cause death and MI, compared with persistent low RIR. These data show that determining RIR in PCI patients identifies a high-risk population. Whether the use of anti-inflammatory medication in this population reduces recurrent cardiovascular events, deserves further investigation.
References
1. de Winter RJ, Heyde GS. Koch KT. The prognostic value of pre-procedural plasma C-reactive protein in patients undergoing elective coronary angioplasty. Eur Heart J 2002;23:960–966.
2. Arroyo-Espliguero R, Avanzas P, Cosın-Sales J, et al. C-reactive protein elevation and disease activity in patients with coronary artery disease. Eur Heart J 2004;25:401–408.
3. Ridker PM, Everett BM, Thuren T, et al. Antiinflammatory therapy with canakinumab for atherosclerotic disease. N Engl J Med 2017;377:1119–1131.
4. Ridker PM. Residual inflammatory risk: addressing the obverse side of the atherosclerosis prevention coin. Eur Heart J 2016;37:1720–1722.
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