Author + information
- Received August 30, 2019
- Revision received October 22, 2019
- Accepted November 15, 2019
- Published online April 20, 2020.
- Amgad Mentias, MD, MSca,∗ ( )(, )
- Milind Y. Desai, MDb,
- Marwan Saad, MD, PhDc,
- Phillip A. Horwitz, MDa,
- James D. Rossen, MDa,
- Sidakpal Panaich, MDa,
- Ayman Elbadawi, MDd,
- J. Dawn Abbott, MDc,
- Paul Sorajja, MDe,
- Hani Jneid, MDf,
- E. Murat Tuzcu, MDb,
- Samir Kapadia, MDb and
- Mary Vaughan-Sarrazin, PhDg
- aDivision of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- bHeart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
- cCardiovascular Institute, The Warren Alpert Medical School at Brown University, Providence, Rhode Island
- dDivision of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
- eValve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
- fDivision of Cardiology, Baylor College of Medicine, Houston, Texas
- gComprehensive Access and Delivery Research and Evaluation Center (CADRE), Iowa City VA Medical Center, Iowa City, Iowa
- ↵∗Address for correspondence:
Dr. Amgad Mentias, University of Iowa, 200 Hawkins Drive, E315 GH, Iowa City, Iowa 52242.
Objectives This study sought to address a knowledge gap by examining the incidence, timing, and predictors of acute coronary syndrome (ACS) after transcatheter aortic valve replacement (TAVR) in Medicare beneficiaries.
Background Evidence about incidence and outcomes of ACS after TAVR is scarce.
Methods We identified Medicare patients who underwent TAVR from 2012 to 2017 and were admitted with ACS during follow-up. We compared outcomes based on the type of ACS: ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. In patients with non–ST-segment elevation ACS, we compared outcomes based on the treatment strategy (invasive vs. conservative) using inverse probability weighting analysis.
Results Out of 142,845 patients with TAVR, 6,741 patients (4.7%) were admitted with ACS after a median time of 297 days (interquartile range: 85 to 662 days), with 48% of admissions occurring within 6 months. The most common presentation was NSTEMI. Predictors of ACS were history of coronary artery disease, prior revascularization, diabetes, valve-in-TAVR, and acute kidney injury. STEMI was associated with higher 30-day and 1-year mortality compared with NSTEMI (31.4% vs. 15.5% and 51.2% vs. 41.3%, respectively; p < 0.01). Overall, 30.3% of patients with non–ST-segment elevation ACS were treated with invasive approach. On inverse probability weighting analysis, invasive approach was associated with lower adjusted long-term mortality (adjusted hazard ratio: 0.69; 95% confidence interval: 0.66 to 0.73; p < 0.01) and higher risk of repeat revascularization (adjusted hazard ratio: 1.29; 95% confidence interval: 1.16 to 1.43; p < 0.001).
Conclusions After TAVR, ACS is infrequent (<5%), and the most common presentation is NSTEMI. Occurrence of STEMI after TAVR is associated with a high mortality with nearly one-third of patients dying within 30 days. Optimization of care is needed for post-TAVR ACS patients and if feasible, invasive approach should be considered in these high-risk patients.
Dr. Mentias has received support from National Institutes of Health NRSA institutional grant (T32 HL007121) to the Abboud Cardiovascular Research Center. Dr. Sarrazin is supported by funding from the National Institute on Aging (R01AG055663-01); and by the Health Services Research and Development Service of the Department of Veterans Affairs. Dr. Horwitz has received grant support from Edwards Lifesciences and Boston Scientific. Dr. Sorajja has received grant support from Edwards Lifesciences, Boston Scientific, Medtronic, and Abbott Structural; and consulting fees from Edwards Lifesciences, Boston Scientific, Medtronic, Abbott Structural, W.L. Gore, Admedus, and Cardionomics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 30, 2019.
- Revision received October 22, 2019.
- Accepted November 15, 2019.
- 2020 American College of Cardiology Foundation
This article requires a subscription or purchase to view the full text. If you are a subscriber or member, click Login or the Subscribe link (top menu above) to access this article.