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Bare-Metal Versus Drug-Eluting Stent Placement Among Patients Presenting With Anemia^_*

Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky

Key Words: acute coronary syndromes • anemia • bare-metal stents • drug-eluting stents • hemoglobin • percutaneous coronary intervention

Beyond anemia being associated with a worse cardiovascular prognosis, there are additional caveats and limitations in caring for such patients. For example, patients with baseline anemia are known to be at increased risk for ACS- and PCI-related bleeding events. Manoukian et al. (3) found anemia to be a strong independent predictor for major bleeding (OR: 1.87, 95% CI: 1.54 to 2.28; p < 0.0001) in the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) study, which assessed bivalirudin versus heparin with platelet IIb/IIIa inhibitors among 13,819 ACS-PCI patients. This and other recent studies (3,4) have also emphasized the relationship between bleeding and subsequent mortality. In the ACUITY study, 30-day mortality was 7.3% versus 1.2% among patients with and without bleeding, respectively (OR: 7.55, 95% CI: 4.68 to 12.18; p < 0.0001). Therefore, as polypharmacy anticoagulation strategies continue to emerge, it can be expected that bleeding will remain a pressing and persistent risk among ACS and PCI patients, particularly as the age of the general population and related comorbidities (e.g., atrial fibrillation) increase (5).

For PCI patients, concerns regarding bleeding continue beyond the catheterization laboratory and the index hospitalization because an ischemia-reduction benefit from long-term dual antiplatelet therapy is established for ACS treatment and separately for drug-eluting stents (DES). A meta-analysis by Serebruany et al. (6) studied the bleeding risks associated with dual-agent versus single-agent therapy and found that dual antiplatelet therapy was associated with an increased relative risk of major (relative risk [RR]: 1.47, 95% CI: 1.36 to 1.60) and minor bleeding events (RR: 1.56, 95% CI: 1.47 to 1.66). Putting these multiple anemia- and bleeding-related issues together, and synergized by concerns for stent thrombosis, it is understandable why there is pause on the part of interventional cardiologists when selecting drug-eluting versus bare-metal stents among patients presenting with anemia.

The paper by Shishehbor et al. (7) in this issue of JACC: Cardiovascular Interventions provides some helpful insight and cause for further reflection. In this first large-scale retrospective study to specifically address the use of DES versus bare-metal stents among anemic patients, the investigators suggest that DES may be used safely in this patient group. Considering a multiyear interval with more than 11,000 PCI patients, 2,172 or roughly 20%, were found to have baseline anemia (as defined by World Health Organization). All-cause mortality at a 1.8-year median follow-up was significantly lower for those treated with DES in unadjusted and multivariable-adjusted Cox proportional models (HR: 0.66, 95% CI: 0.54 to 0.82; p < 0.001). Considering anemia cut points according to hematocrit levels of 28%, 29% to 35%, and 35%, Shishehbor et al. (7) observed mortality to be inversely proportional at approximately 35%, 25%, and 15%, respectively. For each of these hematocrit cut points, mortality was lower for patients receiving DES.

A concept that may be hypothesized from this manuscript is that the heightened mortality risk associated with anemia may necessitate a more effectual form of PCI treatment. Whether any mortality benefit is from the antirestenotic effects of DES, the associated dual-antiplatelet therapy, or undefined factors is uncertain. Because numerous studies have shown that DES are particularly beneficial in higher risk populations—patients with diabetes, end-stage renal disease, and complicated coronary artery disease—it might be plausible that DES provide a net mortality benefit to those with anemia despite increased bleeding risks. As new, more powerful antiplatelet agents such as prasugrel, cangrelor, and ticagrelor (8,9) and newer generation DES are developed, this hypothesis should be considered. Regardless, prospective studies will be needed that collect important information unavailable in the Shishehbor et al. (7) dataset such as bleeding events, stent thrombosis, duration of dual antiplatelet therapy, and other factors associated with the selection of bare-metal stents versus DES in current practice.

	Footnotes

 
Dr. Moliterno has received past honoraria for serving as a member of data safety monitoring committees for stent manufacturers including Boston Scientific and Guidant.

^_* Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology.

^_* Reprint requests and correspondence: Dr. David J. Moliterno, Department of Cardiovascular Medicine, University of Kentucky, 900 South Limestone Avenue, 317 Wethington Building, Lexington, Kentucky 40536-0200 (Email: Moliterno{at}uky.edu).

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