Nonfatal Adverse Events and Risk for Subsequent Mortality in Patients Undergoing Percutaneous Coronary Intervention

Current guidelines and quality metrics after percutaneous coronary intervention (PCI) often assign equal weight to nonfatal adverse events, including heart failure hospitalization (HFH), acute coronary syndrome (ACS), and major bleeding, within composite endpoints.

The aim of this study was to quantify and compare the associations of HFH, ACS, and major bleeding with subsequent mortality following PCI.

A Japanese multicenter prospective PCI registry (2008-2021) with 2-year postprocedural outcomes was analyzed. The primary outcome was all-cause mortality, with HFH, ACS, and major bleeding as time-varying exposures. Cumulative incidence was estimated with death as a competing risk. Cox proportional hazards models and population attributable fractions were used to assess associations between time-varying events and mortality, adjusting for conventional risk factors.

Among 10,482 patients (mean age 69 years, 77.5% men) followed for a median of 730 days (Q1-Q3: 730-730 days), 1,021 (9.7%; 95% CI: 9.2%-10.3%) experienced adverse events. Two-year cumulative incidence rates were 4.7% (95% CI: 4.2%-5.1%) for HFH, 3.4% (95% CI: 3.0%-3.7%) for ACS, and 2.5% (95% CI: 2.2%-2.8%) for major bleeding. Cox analysis showed that HFH was associated with mortality (adjusted HR [aHR]: 6.11; 95% CI: 4.76-7.85), followed by ACS (aHR: 3.22; 95% CI: 2.14-4.84) and major bleeding (aHR: 2.62; 95% CI: 1.71-4.02). Population attributable fraction analysis demonstrated that HFH accounted for 20.1% (95% CI: 19.0%-21.0%) of mortality burden, higher than ACS (4.3%; 95% CI: 3.3%-4.9%) and major bleeding (2.9%; 95% CI: 1.9%-3.5%).

HFH shows stronger associations with mortality than ACS or major bleeding following PCI, suggesting that adverse events should not be weighted equally and underscoring the need to reconsider prioritization in clinical decision-making and endpoint definitions.