History of Cancer Confers Worse PCI Outcomes for Acute MI

Patrice Wendling

November 09, 2016

WASHINGTON, DC — Patients with a history of cancer who undergo PCI for AMI are more likely to die from any cause than patients without a history of malignancy, according to one of the largest studies of its kind[1].

Furthermore, "They stay in the hospital longer, they cost more to the hospital, and they have higher rates of procedure-related complications," co–principal investigator Dr Konstantinos Voudris (University of Illinois at Chicago) reported in a moderated poster session at TCT 2016.

Session moderator Dr Laurent Bonello (Aix-Marseille University, Marseille, France) told heartwire from Medscape that the rising prevalence of cancer and longer life expectancy means "we are seeing more of these patients coming into the cath lab."

He added, "I like the fact that patients with cancer are now treated equally with the others, but still they have a poor prognosis."

Voudris and Bonello said this may be related to several factors, including the malignancy itself, which can cause thrombosis, and anticancer therapies can result in ACS through injury to the vascular system, direct myocardial or pericardial damage, or creation of a hypercoagulable state.

Bonello added, "And of course, we cannot rule out that these patients are not treated as well in terms of cardiovascular medications like the antiplatelet agents. The physician may be reluctant to use the more potent agents because they may provoke more bleeding or side effects or more interactions with the cancer drugs. I think this is a very important area because these patients are frail and we don't know exactly what to do with the cancer drugs either."

To better understand contemporary PCI outcomes in this patient population, Voudris and co–principal investigator Dr Mladen Vidovich (University of Illinois, Chicago) analyzed data from 3,199,349 patients with no malignancy and 246,081 (7.1%) with a history of cancer who underwent PCI for AMI between 2002 and 2013 in the Healthcare Cost and Utilization Project (HCUP)-Nationwide Inpatient Sample (NIS) database, which represents about 20% of all discharges from US hospitals.

At baseline, patients with a history of cancer were significantly older than patients without malignancy (70.9 years vs 62.4 years) and more likely to be female (35.2% vs 32.2%) and have more comorbidities including hypertension (68.8% vs 64.2%), chronic kidney disease (11.8% vs 7.6%), chronic obstructive pulmonary disease (16.3% vs 11.7%), chronic HF (21.1% vs 18.1%), and atrial fibrillation/flutter (15.1% vs 10.4%; P for all <0.0001).

Cancer survivors had significantly worse PCI outcomes than those without malignancy before adjustment, and this difference remained significant for all outcomes after adjustment for baseline covariates in propensity-score–matched analysis.

Outcomes Propensity-Score Matched

Outcome No malignancy Malignancy P
All-cause mortality (%) 3.3 3.9 <0.0001
Length of stay (d) 4.3 4.7 0.005
Total hospital-related costs ($) 53,484 75,135 <0.0001
Cerebrovascular accident (%) 0.8 1.0 <0.0001
Acute kidney injury (%) 3.9 9.0 <0.0001
Blood transfusion (%) 3.5 6.7 <0.0001
Vascular complication (%) 0.3 0.6 <0.0001

It was not possible given the database to determine the interval between cancer diagnosis and PCI or to adjust for whether patients received mainly radiation therapy or chemotherapy, according to Voudris.

There was no difference, however, between groups based on whether bare-metal or drug-eluting stents were used.

Increasing PCI Complexity

A second study by the investigators reported in the same session by Voudris appears to confirm Bonello's view of the changing cath-lab patient population[2]. Using the same data set from the HCUP NIS database, they found the incidence of PCI for AMI in patients with a malignancy increased significantly in the US for all cancer types from 2002 to 2013 (P<0.001).

The highest increase, 78.8% was observed in gynecologic cancers (0.22% vs 0.39%), followed by pulmonary (75.6%), hematologic (72.1%), genitourinary (47.1%), breast (42.8%), gastrointestinal (42.3%), and skin cancer (32.6%).

Voudris observed that this trend suggests an increase in overall complexity of patients presenting with AMI in the US.

Vidovich told heartwire , "Our study is a hypothesis-generating study targeting a very large and high-risk vulnerable population" and that "we aim to stimulate further prospective clinical studies to establish causality and achieve a better understanding of the unique characteristics of this patient population."

Voudris reported no relevant financial relationships. Vidovich reported consultant fees/honoraria from or speaker's bureau participation with Boston Scientific, Daiichi-Sankyo/Eli Lilly, and St Jude Medical; and royalty or intellectual property rights with Merit Medical. Bonello reported grant support/research contracts from AstraZeneca and Boston Scientific.

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