C0317 - Stable Coronary Artery Disease as the Indication for Coronary Stenting Is Associated With a Reduced Risk of Gastrointestinal Bleeding Compared to Acute Coronary Syndrome

Monday, October 24, 2022

3:00 PM – 5:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Pedro Cortes, MD

Mayo Clinic
Jacksonville, FL

Pedro Cortés, MD¹, Christian Karime, MD², Jennifer Zeng, BA¹, Maoyin Pang, MD, PhD²
¹Mayo Clinic, Jacksonville, FL; ²Mayo Clinic Florida, Jacksonville, FL

Introduction: Coronary stenting necessitates the initiation of dual-antiplatelet therapy (DAPT), which is associated with an increased risk of gastrointestinal bleeding (GIB). The indication for coronary stenting may include acute coronary syndrome (ACS: STEMI or NSTEMI), or stable coronary artery disease (CAD). We aimed to determine if the indication for coronary stenting was associated with an increased risk of GIB. Additionally, we aimed to determine if a pre-stenting endoscopy was associated with a reduced risk of GIB, and the frequency of discontinuation of P2Y12 inhibitor after GIB.

Methods: We performed a case-control study of patients who underwent left heart catheterization (LHC) followed by coronary stenting between January 2015 and December 2021 at a single academic center. Clinical data was collected retrospectively. Kaplan-Meier Estimates and Cox Proportional Hazards Regression Analysis were utilized to determine risk factors associated with a GIB following coronary stenting. Statistical analysis was performed utilizing BlueSky Statistics software v. 7.0.

Results: 200 patients were included in the study in a 1:1 ratio of cases and controls. Table 1. The median time to GIB was 166 days (22.8-374.8). At p < 0.10, four variables in the HAS-BLED score at time of LHC were associated with an increased risk of GIB, including hypertension, prior major bleeding, labile INR, and moderate alcohol use. The cumulative HAS-BLED score was not associated with an increased risk of GIB. 32 patients (16.0%) had an endoscopic evaluation within 6 months of coronary stenting. Having had a pre-stenting endoscopy was not associated with a reduced risk of GIB (HR=0.76, 95% CI: 0.41-1.38, p=0.36). Coronary stenting for stable CAD was associated with a 41% reduced risk of GIB compared to patients who had ACS, (HR=0.59, 95% CI: 0.39-0.89, p=0.0113). Figure 1. GIB led to the discontinuation of the prescribed P2Y12 inhibitor in 19% of patients.

Discussion: In our single-center study, we found coronary stenting for stable CAD had a reduced risk of GIB compared to ACS. The acuity of coronary stenting and associated hemodynamic instability in patients with ACS may explain this finding. It is unclear, however, how these variables would increase the risk of GIB occurring at a median of approximately 6 months following stenting. Further study is recommended. Additionally, a GIB following coronary stenting infrequently changes management of the prescribed P2Y12 inhibitor.

Figure: Figure 1: Kaplan-Meier Estimates for A) Time to Gastrointestinal Bleeding after Coronary Stenting for All Patients, B) Time to Gastrointestinal Bleeding by Indication of Coronary Stenting, and C) Time to Gastrointestinal Bleeding by Having had Pre-Catheterization Endoscopy within 6 months of stenting. Legend A: Red = All Patients; Legend B: Blue = STEMI, Red = NSTEMI, Yellow = Stable CAD; Legend C: Blue = Pre-Stenting Endoscopy Performed, Red = Pre-Stenting Endoscopy Not Performed.

Baseline Characteristics Median (IQR) or Fraction (%)		Unadjusted Cox Regression For Index GI Bleeding
	All Patients N=200	HR (95% CI)	p-value
Age at Coronary Stent Placement, per 1 year	70.9 (62.1-78.8)	1.01 (0.85-1.19)	0.94
Male gender	145 (72.5%)	1.09 (0.70-1.71)	0.70
White Race	193 (96.5%)	NA	NA
Hispanic Ethnicity	3 (1.5%)	NA	NA
Never Smoker	68 (34.0%)	0.66 (0.09-4.76)	0.58
Body Mass Index, per 1 kg/m²	29.0 (25.0-34.1)	1.00 (0.97-1.03)	0.98
Obesity	88 (44.0%)	1.19 (0.80-1.76)	0.39
Comorbidities – defined as per HAS-BLED
Hypertension	170 (85.0%)	1.94 (0.98-3.85)	0.0583
Chronic Kidney Disease	34 (17.0%)	0.83 (0.48-1.43)	0.50
Liver Disease	33 (16.5%)	0.91 (0.53-1.58)	0.75
History of stroke	32 (16.0%)	0.74 (0.40-1.35)	0.33
Prior Major Bleeding (before LHC)	73 (36.5%)	0.69 (0.45-1.07)	0.0972
Labile INR	48 (24.0%)	1.49 (0.97-2.30)	0.0695
Age > 65	136 (68.0%)	1.00 (0.66-1.51)	0.99
Medication predisposing to bleeding	200 (100.0%)	NA	NA
Alcohol use	43 (21.5%)	1.55 (0.99-2.42)	0.0560
HAS-BLED score	4 (3-5)	1.05 (0.89-1.23)	0.58
Coronary Catheterization Data
Pre-catheterization Endoscopy Performed	32 (16.0%)	0.76 (0.41-1.38)	0.36
· Delay in LHC due to endoscopy	4/32 (12.5%)	0.97 (0.12-7.75)	0.98
Indication for coronary catheterization
· Acute Coronary Syndrome	112 (56%)	1.70 (1.13-2.57)	0.0113
o NSTEMI	70 (35.0%)	1.40 (0.94-2.09)	0.0970
o STEMI	42 (21.0%)	1.34 (0.85-2.13)	0.21
· Stable CAD	88 (44.0%)	0.59 (0.39-0.89)	0.0113
Number of Stents Placed, per 1 stent	1 (1-2)	1.23 (0.99-1.53)	0.0657
· 3 or more stents placed	29 (14.5%)	1.56 (0.96-2.55)	0.0757
Hemoglobin prior to catheterization, per 1 g/dL	12.7 (10.5-14.1)	0.98 (0.90-1.06)	0.61
Medications After Catheterization
Proton pump inhibitor	77 (38.5%)	0.73 (0.48-1.12)	0.15
SSRI	26 (13.0%)	0.81 (0.44-1.48)	0.49
NSAIDs	3 (1.5%)	NA	NA
Anticoagulation	65 (32.5%)	1.95 (1.30-2.91)	0.0012
· Warfarin	39/65 (60.0%)	1.20 (0.63-2.26)	0.58
· DOAC	24/65 (36.9%)	0.83 (0.43-1.58)	0.56
Indication for Anticoagulation
· Atrial Fibrillation	52/65 (80.0%)	0.58 (0.28-1.23)	0.16
· DVT/PE	9/65 (13.8%)	1.33 (0.56-3.16)	0.52
Gastrointestinal Bleed (GIB)	Patients with GIB N = 100
Median time to Index GIB, days	166 (22.8-374.8)	NA	NA
P2Y12 inhibitor taken prior to admission	89/100 (89.0%)	NA	NA
P2Y12 inhibitor Discontinued due to GIB	19/100 (19.0%)	NA	NA

Table: Table 1: Baseline Characteristics of All Patients and Cox Proportional Hazard Regression Analysis for the Occurrence of GI Bleed Following Coronary Stenting

Disclosures:

Pedro Cortés indicated no relevant financial relationships.

Christian Karime indicated no relevant financial relationships.

Jennifer Zeng indicated no relevant financial relationships.

Maoyin Pang indicated no relevant financial relationships.

Pedro Cortés, MD¹, Christian Karime, MD², Jennifer Zeng, BA¹, Maoyin Pang, MD, PhD². C0317 - Stable Coronary Artery Disease as the Indication for Coronary Stenting Is Associated With a Reduced Risk of Gastrointestinal Bleeding Compared to Acute Coronary Syndrome, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.