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

      To the Editor:
      We deeply appreciate and commend Ganatra et al
      • Ganatra S.
      • Sharma A.
      • Levy M.S.
      A differing opinion on primary percutaneous coronary intervention in patients who have had cancer: stent choice in onco-cardiology revisited.
      for the points they raised, namely, that cancer patients who have coronary artery disease requiring treatment may not be well served by withholding drug-eluting stents (DESs). As they rightly state, it is often feared that these patients might suffer a bleeding event or undergo an intervention that could compromise the duration of dual antiplatelet therapy (DAPT). Intriguingly, an updated recommendation on the minimum duration of DAPT after DES placement was released by the American College of Cardiology/American Heart Association just last year, and therapy for 6 months was considered sufficient as a general recommendation, that is, for all patients.
      • Levine G.N.
      • Bates E.R.
      • Bittl J.A.
      • et al.
      2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: an update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.
      As the authors further indicate, newer generation DESs are even safer than bare-metal stents in terms of stent thrombosis and mortality.
      • Palmerini T.
      • Benedetto U.
      • Biondi-Zoccai G.
      • et al.
      Long-term safety of drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis.
      Accordingly, one may argue that DES use should not be feared, even in cancer patients.
      Data on this very topic are, however, scarce, and even more so when it comes to systematically obtained data and clinical trials. Our study, as implicated by Ganatra et al,
      • Ganatra S.
      • Sharma A.
      • Levy M.S.
      A differing opinion on primary percutaneous coronary intervention in patients who have had cancer: stent choice in onco-cardiology revisited.
      therefore presents an opportunity to surveil and compare the treatment of coronary artery disease patients with and without cancer. Truly, it is a striking observation that only 40% of the cancer patients who suffered an ST-elevation myocardial infarction received DESs in our study,
      • 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.
      in view of an average DES utilization rate of 70% to 75% in general.
      • 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.
      • Bangalore S.
      • Gupta N.
      • Guo Y.
      • Feit F.
      Trend in the use of drug eluting stents in the United States: insight from over 8.1 million coronary interventions.
      We should note, however, that DES use was low even in the noncancer group (50%) in our study.
      • 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.
      One likely explanation is that our analysis started in 2000 and it was not until later in 2003 that DESs became available for clinical practice. Thus, nearly one-third of the entire enrollment period for our study was in an era when bare-metal stents were the only available stent choice. Indeed, recalculating the numbers only for the time when DESs were available (and assuming equal annual patient volume) would yield a DES rate of 78.1% in the noncancer group, but only 59.8% in the cancer cohort. Accordingly, the DES utilization rates we report are not very different from national reports for the overall cohort of patients with ST-elevation myocardial infarction (STEMI), whereas DES utilization rates are lower in patients with STEMI with a cancer history.
      As a limitation to our study, we did not have data extending into the most current era and stratified by years to assess whether trends changed over time as newer generation DESs became available. We were also not in a position to gauge the reasons for the use or nonuse of DESs in our cohort. It is likely that the comfort level of DESs varies with exposure, as it does with performing percutaneous coronary intervention (PCI) on patients with low platelet counts.
      • Yusuf S.W.
      • Iliescu C.
      • Bathina J.D.
      • Daher I.N.
      • Durand J.B.
      Antiplatelet therapy and percutaneous coronary intervention in patients with acute coronary syndrome and thrombocytopenia.
      Centers that treat a higher volume of cancer patients with STEMIs, including even those who are undergoing active cancer treatment (eg, MD Anderson in Houston, TX) document improved survival outcomes when adhering to guideline-recommended therapies including aspirin in patients with thrombocytopenia and PCI for acute coronary syndromes.
      • Sarkiss M.G.
      • Yusuf S.W.
      • Warneke C.L.
      • et al.
      Impact of aspirin therapy in cancer patients with thrombocytopenia and acute coronary syndromes.
      • Yusuf S.W.
      • Daraban N.
      • Abbasi N.
      • Lei X.
      • Durand J.B.
      • Daher I.N.
      Treatment and outcomes of acute coronary syndrome in the cancer population.
      The consensus document of the Society of Cardiac Angiography and Intervention summarizes these experiences and provides recommendations in regard to the management of cancer patients referred to the catheterization laboratory. As a unique aspect, decisions on whether to proceed with PCI and which type of PCI to use depend on the clinical presentation, estimated survival prognosis, platelet count, and planned therapy.
      • Iliescu C.A.
      • Grines C.L.
      • Herrmann J.
      • et al.
      SCAI Expert consensus statement: evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (endorsed by the Cardiological Society of India, and sociedad Latino Americana de Cardiologia intervencionista).
      At present there are no data on how systemic chemotherapies influence the response to PCI injury and stent reendothelialization. Suffice it to say, many of the drugs used for stent coating are in essence chemotherapeutics (eg, paclitaxel and everolimus). One may therefore postulate that patients with cancer, especially those on active, potent antiproliferative chemotherapy, will require a prolonged duration of DAPT. This postulate is supported by a single-center study on more than 7000 patients documenting a 7-fold higher incidence of stent thrombosis in patients with coronary artery disease with concomitant malignancy.
      • Gross C.M.
      • Posch M.G.
      • Geier C.
      • et al.
      Subacute coronary stent thrombosis in cancer patients.
      Importantly, this particular study excluded patients with DESs, and all cancer patients with in-stent thrombosis had solid cancers.
      The unique aspects of cardiovascular care of cancer patients will continue to require further and more comprehensive studies. Ganatra et al
      • Ganatra S.
      • Sharma A.
      • Levy M.S.
      A differing opinion on primary percutaneous coronary intervention in patients who have had cancer: stent choice in onco-cardiology revisited.
      provide valid points in line with our report that optimal cardiovascular therapy should not be withheld from cancer patients. This may include DESs, and importantly prolonged DAPT after any type of stent implantation.

      References

        • Ganatra S.
        • Sharma A.
        • Levy M.S.
        A differing opinion on primary percutaneous coronary intervention in patients who have had cancer: stent choice in onco-cardiology revisited.
        Mayo Clin Proc. 2017; 92: 1315-1316
        • Levine G.N.
        • Bates E.R.
        • Bittl J.A.
        • et al.
        2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: an update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.
        Circulation. 2016; 134 (Erratum in: Circulation. 2016;134(10):e192-e194): e123-e155
        • Palmerini T.
        • Benedetto U.
        • Biondi-Zoccai G.
        • et al.
        Long-term safety of drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis.
        J Am Coll Cardiol. 2015; 65: 2496-2507
        • 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
        • Bangalore S.
        • Gupta N.
        • Guo Y.
        • Feit F.
        Trend in the use of drug eluting stents in the United States: insight from over 8.1 million coronary interventions.
        Int J Cardiol. 2014; 175: 108-119
        • Yusuf S.W.
        • Iliescu C.
        • Bathina J.D.
        • Daher I.N.
        • Durand J.B.
        Antiplatelet therapy and percutaneous coronary intervention in patients with acute coronary syndrome and thrombocytopenia.
        Tex Heart Inst J. 2010; 37: 336-340
        • Sarkiss M.G.
        • Yusuf S.W.
        • Warneke C.L.
        • et al.
        Impact of aspirin therapy in cancer patients with thrombocytopenia and acute coronary syndromes.
        Cancer. 2007; 109: 621-627
        • Yusuf S.W.
        • Daraban N.
        • Abbasi N.
        • Lei X.
        • Durand J.B.
        • Daher I.N.
        Treatment and outcomes of acute coronary syndrome in the cancer population.
        Clin Cardiol. 2012; 35: 443-450
        • Iliescu C.A.
        • Grines C.L.
        • Herrmann J.
        • et al.
        SCAI Expert consensus statement: evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (endorsed by the Cardiological Society of India, and sociedad Latino Americana de Cardiologia intervencionista).
        Catheter Cardiovasc Interv. 2016; 87: e202-e223
        • Gross C.M.
        • Posch M.G.
        • Geier C.
        • et al.
        Subacute coronary stent thrombosis in cancer patients.
        J Am Coll Cardiol. 2008; 51: 1232-1233

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