NEW YORK (Reuters Health) – Cancer patients who sustain a heart attack were less likely than non-cancer patients to be treated with percutaneous coronary intervention (PCI) in a retrospective study.
The authors say PCI is “underutilized” in cancer patients, despite comparable rates of in-hospital mortality and major adverse cardiovascular and cerebrovascular events (MACCE) to patients without cancer.
Cancer patients who sustain a heart attack often don’t receive PCI “because the benefits…are unknown, as many of the landmark research trials that studied the effectiveness of these procedures excluded patients with cancer, and (these) patients may be at increased risk from procedural complications such as major bleeding,” Dr. Mamas Mamas of Keele University, UK, told Reuters Health by email.
“We found that patients with cancer are up to 50% less likely to receive PCI compared to patients without cancer,” he said. “Yet we found that if offered this treatment, they have as much benefit as patients without cancer. PCI saves lives in the setting of ST-elevation myocardial infarction (STEMI), irrespective of whether the patient has cancer or not.”
As reported in the European Heart Journal, Dr. Mamas and colleagues analyzed records of more than a million patients from the National Inpatient Sample between 2004 and 2015.
Close to 39,000 (2.1%) had a current cancer diagnosis, of which 29% were hematological; 25%, prostate; 24.5%, lung; 12%, breast; and 9.6%, colon.
The majority of non-cancer patients received PCI for STEMI (82.3%) whereas the rates of PCI were much lower in the current cancer groups (54.2-70.6%), especially those with lung cancer (54.2%).
In both groups, patients who underwent PCI were generally younger and more likely to be male, privately insured or self-payers, and admitted to larger bed size and urban teaching hospitals. They also had a lower prevalence of atrial fibrillation, anemia, heart or renal failure, chronic pulmonary disease, and dementia, and a higher prevalence of risk factors such as dyslipidemia and ventricular arrhythmias.
Those who underwent PCI in the cancer groups were more likely than those who did not to have cardiogenic shock. They were also more likely to have a single vessel intervention and receive bare metal (vs. drug-eluting) stents.
In both groups, overall, crude rates of MACCE, all-cause mortality, acute stroke, and major bleeding were significantly higher in the those who did not receive PCI. No differences in major bleeding probabilities were seen between PCI and no PCI subgroups across all cancer types.
Further, the average treatment effect of PCI on MACCE and mortality in the cancer groups was at least equal to, or in some cases greater, than the no-cancer group.
Dr. Nathaniel Smilowitz, an interventional cardiologist and assistant professor of medicine at NYU Langone Health, called the findings “sobering.” He noted, “It is reassuring to see that PCI was associated with more favorable in-hospital outcomes in STEMI patients with and without active cancer. A diagnosis of cancer should not prohibit the invasive management of STEMI with primary PCI in many cases.”
“Appropriate goals of care conversations between patients and their providers may have led to the lower rates of primary PCI,” he suggested. “Furthermore, selection bias in the decision to pursue primary PCI cannot be excluded, despite matching, due to unmeasured confounders relevant to patients with cancer, such as functional status, bleeding risks and the presence of intracranial metastatic disease, long-term oncologic prognosis, and individual goals of care.”
“These findings warrant further investigation,” Dr. Smilowitz concluded.
SOURCE: https://bit.ly/2NmDKTa European Heart Journal, online February 4, 2021.