Cirrhosis Tied to Poor Outcomes in the Months After PCI

Patients with cirrhosis are a particularly high-risk group when it comes to undergoing PCI, new data affirm.

Cirrhosis, though relatively rare among patients treated over a recent 5-year span, was associated with higher rates of mortality, readmissions, and adverse events as well as increased costs within the first 90 days, according to researchers led by Daniel Lu, MD (Weill Cornell Medical College and NewYork-Presbyterian Hospital, New York, NY).

Prior studies, Lu told TCTMD, have suggested that even though patients with cirrhosis have higher risks during PCI, it is still generally safe to perform the procedures. These new data, however, reveal very high risks, he said, citing the mortality rate of around 10% and total adverse event rate above 40%.

“That puts into perspective the difficulties of doing this procedure in a patient population like this and really highlights the importance that providers who do these procedures in these cirrhotics really have to be aware just how sick these patients are, just how high risk the patients are, and just how poor the outcomes can be if they don’t pay attention to it,” Lu said.

The study, published online February 8, 2020, ahead of print in the American Journal of Cardiology, also “highlights the fact that we should only do these procedures when absolutely necessary with experienced providers who are aware of these risks and utilize strategies to minimize these risks as much as possible,” he added. Using transradial access, correcting patient coagulopathy, minimizing contrast use, and potentially reducing the duration of dual antiplatelet therapy (DAPT) after the procedure are all possible approaches, he said. “People should be optimizing these patients from a cirrhotic and liver perspective before they undergo these PCI procedures, as well.”

Providers who do these procedures . . . really have to be aware just how sick these patients are, just how high risk the patients are, and just how poor the outcomes can be if they don’t pay attention to it. Daniel Lu

In 2016, Abhijit Ghatak, MD (Cardiovascular Clinic of North Georgia, Lawrenceville), and colleagues published data showing that PCI was a safe and feasible option in patients with cirrhosis, albeit with higher in-hospital risks.

The study by Lu et al adds to the existing literature by exploring risks out to 90 days, Ghatak commented to TCTMD, noting, however, that the data are from 2010 to 2014. “There has been improvement in stent design, imaging technique, and DAPT duration since then and the contemporary numbers may be slightly better than as stated in this study,” he said in an email. “However, it clearly highlights that these patients with [end-stage liver disease] are at a higher risk of periprocedural complications and more caution and a patient-focused approach is needed when performing PCI in these patients.”

A Vulnerable Group

Patients with cirrhosis are especially susceptible to the PCI complications, Lu explained, because they often have underlying kidney disease and have issues with bleeding, thrombocytopenia, and coagulopathies. But because surgical revascularization is usually too risky, he added, they’re often referred for PCI.

Previous studies demonstrating heightened risks in the presence of cirrhosis generally have examined only short-term outcomes or have included small numbers of patients, with none exploring longer-term outcomes in a large population.

In this new study, the investigators turned to the Nationwide Readmissions Database, identifying more than 1.8 million index admissions that included PCI between 2010 and 2014; 7,125 of those (0.4%) involved patients with a diagnosis of cirrhosis or cirrhosis-related complications.

Patients with cirrhosis had a higher burden of comorbidities, including higher rates of anemia, coagulopathy, and chronic kidney disease. They were less likely to present with STEMI, but they were more likely to have cardiogenic shock and cardiac arrest and to require percutaneous mechanical circulatory support.

During the initial hospitalization, patients with cirrhosis had a longer mean stay (7.7 vs 3.6 days) and a higher mortality rate (7.0% vs 1.8%).

Poorer outcomes among these patients persisted through 90 days of follow-up, with higher rates of mortality (10.3% vs 2.5%), readmissions (38.2% vs 20.2%), and total adverse events (44.7% vs 17.7%; P < 0.01 for all). Specifically, cirrhosis was associated with higher rates of GI bleeding (15.3% vs 2.7%), acute kidney injury (28.4% vs 10.1%), and transfusion (18.6% vs 5.0%; P < 0.01 for all). p<0.01). All of those differences remained significant after multivariable adjustment.

It was also more expensive to care for patients with cirrhosis, with higher mean costs during the index hospitalization and throughout the 90-day follow-up.

Careful Patient Selection Key

Ghatak stressed the importance of patient selection when considering PCI in a patient with cirrhosis.

“Apart from a STEMI situation, the mortality associated with the liver disease should be weighed against the mortality and morbidity associated with their cardiovascular disease,” he said. Risk scores specifically designed for patients with end-stage liver disease, like the MELD score and the Child-Pugh score, “should be taken into account, and also a cardiology, hematology, and hepatology team approach needs to be implemented before embarking on PCI on these patients.”

The authors also touted an individualized approach in this patient population. “These high rates of adverse outcomes and increased hospital costs emphasize the careful patient selection and thorough risk-benefit evaluation that may be needed prior to performing PCI in this very sick population, especially as only 18.5% of the cirrhotics in our study presented with STEMI,” they say.

Ghatak added that once the decision to perform PCI has been made, DES should be preferred when choosing a stent and DAPT duration should be limited as much as possible. In this study, DES, which were associated with improved outcomes, were less likely to be used in the patients with cirrhosis (53.4% vs 78.0%).

“The reason for less use of DES is related to the concern of longer-term DAPT in this patients,” Ghatak said. “However, with the newer studies and decrease in the length of DAPT post-DES, the use of DES should be considered upfront in these patients rather that BMS.”