November 10, 2015 – The DCRI’s Amit N. Vora, MD, MPH, and others revealed substantial hospital-level variation in practices, highlighting the lack of clear guidelines for stent use in this population.
Controversy remains around the most appropriate type of stent – drug-eluting or bare metal – to use in heart attack patients with atrial fibrillation. Stent selection for this population has important implications for duration of antithrombotic therapy. This study set out to analyze trends in practices across the United States.
Compared with bare metal stents, drug-eluting devices pose a lower risk of restenosis, where the artery narrowing recurs, but a higher risk of stent thrombosis, where a blood clot forms within the stent. To mitigate this thrombosis risk, patients with drug-eluting stents receive dual antiplatelet therapy, which prevents platelets from clumping and clots from forming and growing. This additional therapy represents an added layer of risk for those with atrial fibrillation, who already need to take anticoagulant therapy to reduce stroke risk.
The results of the study were announced Tuesday at the 2015 American Heart Association (AHA) Scientific Sessions in Orlando, Florida.
The authors found that heart attack patients with atrial fibrillation are more likely to receive a drug-eluting stent than a bare metal stent, and that use of drug-eluting stents in these patients has increased over time. This applied even to patients with both high predicted stroke risk and bleeding risk. There was also substantial variation in practices between hospitals. Patients with atrial fibrillation who received a drug-eluting stent were, however, less likely to receive warfarin therapy at discharge.
“The variation in practices between hospitals in this high-risk population reflects the current lack of clear guidance, and the need for additional research on stent selection and antithrombotic strategy,” said lead author Amit Navin Vora, MD, MPH. “As a next step, outcomes data should be examined.”
These findings were based on data from 14,427 atrial fibrillation patients presenting with acute myocardial infarction to 652 hospitals from 2008-2014. The data came from the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network Registry®-Get With the Guidelines™ (ACTION Registry-GWTG). This risk-adjusted, outcomes-based quality improvement program focuses exclusively on high-risk STEMI (ST-segment elevation myocardial infarction) and NSTEMI (non-ST-segment elevation myocardial infarction) patients.
In addition to Vora, Duke co-authors included Tracy Y. Wang, MD, MHS, MSc; Shuang Li, MS; Karen Chiswell, PhD; Sunil V. Rao, MD; and Eric D. Peterson, MD, MPH.