Ischaemic and bleeding risk after ST-elevation myocardial infarction in patients with active cancer: a nationwide
Mohamed Dafaalla1, Francesco Costa2,3,4, Haibo Jia5
1Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele Rd, Keele ST5 5BG, UK.
Insights
Patients with cancer experiencing ST-elevation myocardial infarction (STEMI) face a higher risk of major bleeding but not re-infarction. Managing bleeding complications is crucial for improving outcomes in these complex cases.
Area of Science:
- Cardiology
- Oncology
- Clinical Research
Background:
- Treatment for ST-elevation myocardial infarction (STEMI) in cancer patients is complicated by elevated risks of thrombotic and bleeding events.
- Cancer patients often present with more comorbidities and receive less invasive treatment compared to non-cancer patients.
Purpose of the Study:
- To investigate the comparative risks of major bleeding and re-infarction in STEMI patients with and without active cancer.
- To inform clinical management strategies for STEMI patients with cancer.
Main Methods:
- A national cohort study linked UK Myocardial Infarction National Audit Project and Hospital Episode Statistics data from January 2005 to March 2019.
- Identified 322,776 STEMI admissions, with 7,050 (2.2%) diagnosed with active cancer.
- Primary outcomes were major bleeding and re-infarction at 1 year, analyzed using survival analysis.
Main Results:
- Cancer patients were older, had more comorbidities, and underwent fewer invasive procedures (angiography, PCI) and less dual antiplatelet therapy.
- The incidence of major bleeding was significantly higher in cancer patients (6.5% vs. 3.5%).
- After adjustment, cancer patients had a similar risk of re-infarction (SHR 1.10) but a 50% increased risk of major bleeding (SHR 1.49).
Conclusions:
- STEMI patients with cancer experience a significantly higher risk of major bleeding compared to those without cancer.
- The risk of re-infarction is comparable between cancer and non-cancer STEMI patients.
- Strategies to mitigate bleeding risk are essential for improving outcomes in STEMI patients with cancer.
Aims:
Treatment of patients with cancer presenting with ST-elevation myocardial infarction (STEMI) is complex given the increased risk of both thrombotic and major bleeding complications.
Methods And Results:
A nationally linked cohort of STEMI patients between January 2005 and March 2019 was obtained from the UK Myocardial Infarction National Audit Project and the UK National Hospital Episode Statistics Admitted Patient Care registries. The primary outcomes were major bleeding and re-infarction at 1 year following admission with STEMI. Major bleeding was defined as bleeding events that require hospital admission. Re-infarction was defined as acute MI according to the fourth Universal Definition of Myocardial Infarction. A total of 322 776 STEMI-indexed admissions were identified between January 2005 and March 2019. Of those, 7050 (2.2%) patients were diagnosed with active cancer. Cancer patients were older with more cardiovascular comorbidities. Cancer patients received invasive coronary angiography (62.2% vs. 72.7%, P < 0.001) and percutaneous coronary intervention (58.4% vs. 69.5%, P < 0.001) less often compared with patients without cancer and were less likely to be prescribed dual antiplatelet therapy (85% vs. 95.4%, P < 0.001). The incidence of major bleeding (6.5% vs. 3.5%, P < 0.001) and re-infarction (cancer 5.7%, no cancer 5.1%, P = 0.01) was higher in cancer patients at 1 year. After adjustment for differences in baseline covariates, a similar risk of re-infarction (sub-hazard ratios (SHR) 1.10, 95% CI 0.94-1.27) and a 50% increased risk of major bleeding (SHR 1.49, 95% CI 1.30-1.71) were observed in cancer patients.
Conclusion:
Compared with non-cancer patients, cancer patients have a higher risk of major bleeding but not of re-infarction. Mitigating bleeding risk in STEMI patients with cancer is of paramount importance to improve outcomes.
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