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A Differing Opinion on Primary Percutaneous Coronary Intervention in Patients Who Have Had Cancer: Stent Choice in Onco-cardiology Revisited

      To The Editor:
      We are writing in reference to the report of Wang et al
      • Wang F.
      • Gulati R.
      • Lennon R.J.
      • et al.
      Cancer history portends worse acute and long-term noncardiac (but not cardiac) mortality after primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction.
      titled “Cancer History Portends Worse Acute and Long-term Noncardiac (but Not Cardiac) Mortality After Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial Infarction,” as well as the accompanying editorial by Al-Kindi and Oliveira
      • Al-Kindi S.G.
      • Oliveira G.H.
      Onco-cardiology: a tale of interplay between 2 families of diseases.
      titled “Onco-Cardiology: A Tale of Interplay Between 2 Families of Diseases,” published in the December 2016 issue of Mayo Clinic Proceedings. Specifically, we wish to expound upon our differing opinion on the use of coronary artery stents in select onco-cardiology patients.
      The study by Wang et al
      • Wang F.
      • Gulati R.
      • Lennon R.J.
      • et al.
      Cancer history portends worse acute and long-term noncardiac (but not cardiac) mortality after primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction.
      demonstrated the importance of aggressive cardiovascular care in patients with a history of cancer, but also suggested that these patients are less likely to receive drug-eluting stents (DESs) to treat coronary artery disease (CAD), out of concern for high bleeding risk and expectant need for cancer-directed surgery. Although characterized as a “safe” treatment strategy, in our opinion, it might not be optimal for all patients with CAD and a history of cancer.
      Many of the clinical risk factors for cancer such as diabetes mellitus, smoking, and a chronic inflammatory state are also risk factors for coronary artery restenosis and thrombosis after stenting. The current generation of DES reduces the risk of restenosis and stent thrombosis as compared with bare-metal stents.
      • Morice M.C.
      • Serruys P.W.
      • Sousa J.E.
      • et al.
      RAVEL Study Group
      Randomized study with the sirolimus-coated Bx velocity balloon-expandable stent in the treatment of patients with de novo native coronary artery lesions: a randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization.
      It was previously felt that the biggest disadvantage of DESs was the requirement of dual antiplatelet therapy (DAPT) for at least 12 months after stent placement. This interpretation of anticoagulant therapy resulted from the experience with first-generation DESs, in which it was inferred that DES stent failure was more likely because of inhibition of neointimal formation resulting in incomplete endothelialization.
      • Camenzind E.
      • Steg P.G.
      • Wijns W.
      Stent thrombosis late after implantation of first-generation drug-eluting stents: a cause for concern.
      However, data on the current generation of DES calls this interpretation of the pathophysiology into question.
      A prespecified analysis from the Zatarolimus-Eluting Endeavour Sprint Stent in Uncertain DES Candidates (ZEUS) trial found that patients with high bleeding risk and those receiving stents that slowly eluted zotarolimus (an immunosuppressant) had a lower rate of stent thrombosis, myocardial infarction, and target vessel revascularization compared with those receiving bare-metal stents, despite shorter duration of DAPT (15-60 days). Furthermore, rates of bleeding events did not differ between the 2 stent groups.
      • Ariotti S.
      • Adamo M.
      • Costa F.
      • et al.
      Is bare-metal stent implantation still justifiable in high bleeding risk patients undergoing percutaneous coronary intervention? A pre-specified analysis from the ZEUS trial.
      Additional evidence is inferred in studies looking at patients with thoracic malignancies: Mediastinal radiotherapy decreases mortality and malignancy recurrence but is associated with a 7-fold increased risk of CAD. Surgical revascularization is often necessary but is associated with high perioperative complications due to unsuitability of the left internal mammary artery following irradiation. Bare-metal stents, in this population, have been associated with very high rates of in-stent restenosis. In contrast, the newer DESs have shown no difference in the rate of in-stent restenosis between irradiated and nonirradiated patients,
      • Liang J.J.
      • Sio T.T.
      • Slusser J.P.
      • et al.
      Outcomes after percutaneous coronary intervention with stents in patients treated with thoracic external beam radiation for cancer.
      which makes them preferable in this population.
      Although cancer patients may be considered at high risk for bleeding, this risk is not equivalent in all patients with a history of cancer. Cardiovascular disease in patients with cancer is complex, and treatment needs to be individualized. There is evidence to suggest that refraining from the use of DES in this rapidly expanding cohort can lead to higher major cardiovascular events, which can thwart the effectiveness of advancements in both fields. Given more current data demonstrating improved efficacy with DESs and short-duration DAPT, without an increase in bleeding risk, perhaps it is time to rethink our strategy in cancer patients who undergo percutaneous coronary intervention.

      References

        • Wang F.
        • Gulati R.
        • Lennon R.J.
        • et al.
        Cancer history portends worse acute and long-term noncardiac (but not cardiac) mortality after primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction.
        Mayo Clin Proc. 2016; 91: 1680-1692
        • Al-Kindi S.G.
        • Oliveira G.H.
        Onco-cardiology: a tale of interplay between 2 families of diseases.
        Mayo Clin Proc. 2016; 91: 1675-1677
        • Morice M.C.
        • Serruys P.W.
        • Sousa J.E.
        • et al.
        • RAVEL Study Group
        Randomized study with the sirolimus-coated Bx velocity balloon-expandable stent in the treatment of patients with de novo native coronary artery lesions: a randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization.
        N Engl J Med. 2002; 346: 1773-1780
        • Camenzind E.
        • Steg P.G.
        • Wijns W.
        Stent thrombosis late after implantation of first-generation drug-eluting stents: a cause for concern.
        Circulation. 2007; 115 (discussion 1455): 1440-1455
        • Ariotti S.
        • Adamo M.
        • Costa F.
        • et al.
        Is bare-metal stent implantation still justifiable in high bleeding risk patients undergoing percutaneous coronary intervention? A pre-specified analysis from the ZEUS trial.
        JACC Cardiovasc Interv. 2016; 9: 426-436
        • Liang J.J.
        • Sio T.T.
        • Slusser J.P.
        • et al.
        Outcomes after percutaneous coronary intervention with stents in patients treated with thoracic external beam radiation for cancer.
        JACC Cardiovasc Interv. 2014; 7: 1412-1420

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