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

      To the Editor:
      We sincerely welcome the letter 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.
      describing their concern regarding the use of bare-metal stents (BMSs) in patients with cancer. The authors raise important questions regarding the best strategy for percutaneous revascularization in this cohort.
      It is important to consider 3 important factors before coronary revascularization in patients with cancer. First, patients with cancer may be at higher bleeding risk due to coagulopathy and the expected need for cancer-related surgeries. Second, cancer is associated with a prothrombotic state that may increase the risk for in-stent thrombosis. Third, many patients with cancer have limited life expectancy, which may compete with coronary events as the principle source of morbidity and mortality.
      Thus, it is conceivable that BMSs may be preferable in patients with cancer because they are associated with lower risk of in-stent thrombosis, allowing for earlier interruption of dual antiplatelet therapy (DAPT). It is correct that BMS use is at the expense of increased risk of in-stent restenosis and need for target lesion revascularization; however, these are typically late events that are rare and many patients die from cancers before in-stent restenosis ensues.
      The authors extrapolate data from the Zotarolimus-eluting Endeavor sprint stent in Uncertain DES candidates (ZEUS) trial, which showed that zotarolimus-eluting coronary stents were associated with decreased risk of 1-year major adverse cardiovascular events (death, myocardial infarction, or target vessel revascularization) when compared with BMSs, despite similarity in the duration of DAPT.
      • Valgimigli M.
      • Patialiakas A.
      • Thury A.
      • et al.
      ZEUS Investigators
      Zotarolimus-eluting versus bare-metal stents in uncertain drug-eluting stent candidates.
      It is important to note, however, that out of 1606 patients enrolled in this trial, only 5.2% (84 of 1606) patients had cancer and only 19% (305 of 1606) had ST-elevation myocardial infarction (STEMI), thus limiting the generalizability of these data to all cancer patients with STEMI.
      The emerging data on the safety of shorter periods of DAPT in drug-eluting stents (DESs) may make them more appropriate for use in patients with cancer. The 2016 update of the American College of Cardiology/American Heart Association guidelines on DAPT duration after coronary stenting now recommends 6 months of DAPT after DES placement in patients who have stable ischemic heart disease and 12 months after DES placement in patients who have had a myocardial infarction.
      • Bates E.R.
      • Mauri L.
      • Bittl J.A.
      • Mehran R.
      2016 ACC/AHA Guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease.
      It is important to note, however, that because many patients with active cancer have heightened thrombosis risk, extended DAPT may be appropriate in selected patients. It is essential to individualize this risk and balance it against the bleeding risk to optimize outcomes. For example, one study showed that the duration of DAPT can be determined on the basis of poststenting intravascular imaging in patients with cancer, allowing earlier interruption of DAPT.
      • Iliescu C.
      • LeBeau J.T.
      • Silva G.
      • et al.
      Optical coherence tomography-guided antiplatelet therapy in patients with coronary artery disease and cancer: the PROTECT-OCT registry.
      Thus, the 2016 Society for Cardiac Angiography and Interventions Expert Consensus Statement suggests using newer generation DESs in patients with cancer who have a platelet count of more than 30,000.
      • 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 Cardiologıa intervencionista).
      We agree that the current preference of BMSs in cancer patients is dependent on clinical experience and is not driven by evidence, simply because randomized trials have generally excluded patients with cancer. We believe that the therapeutic approach should be individualized, highlighting the need for interventional cardiologists with an understanding of onco-cardiology.
      The authors also discussed the optimal therapeutic approach in patients who have coronary artery disease and who received mediastinal radiation. Although this was not explicitly discussed by Wang et al,
      • Wang F.
      • Gulati R.
      • Lennon R.J.
      • et al.
      Cancer history portends worse acute and long-term non-cardiac (but not cardiac) mortality after primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction.
      we agree with the authors that care in these patients also needs to be individualized. The authors correctly report that these patients are at increased risk for in-stent restenosis, especially after placement of BMSs.
      • 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.
      In a retrospective cohort analysis of 157 patients with a history of mediastinal radiation who underwent coronary stenting in one center, BMS use, but not DES, was associated with increased risk of long-term mortality compared with matched controls.
      • Reed G.W.
      • Masri A.
      • Griffin B.P.
      • Kapadia S.R.
      • Ellis S.G.
      • Desai M.Y.
      Long-term mortality in patients with radiation-associated coronary artery disease treated with percutaneous coronary intervention.
      The lack of data to guide treatment strategies in these complex patients is alarming. There needs to be an urgent call for prospective research to address these and other unresolved questions in the field. Until we get prospective data, treatment strategies should be individualized, and a multidisciplinary approach to patient care (with oncologists and cardiologists contributing) should be encouraged.

      References

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        • 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.
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        • Patialiakas A.
        • Thury A.
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        • Mauri L.
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        • Silva G.
        • et al.
        Optical coherence tomography-guided antiplatelet therapy in patients with coronary artery disease and cancer: the PROTECT-OCT registry.
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        • Grines C.L.
        • Herrmann J.
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        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 Cardiologıa intervencionista).
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        • Wang F.
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        Cancer history portends worse acute and long-term non-cardiac (but not cardiac) mortality after primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction.
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        Long-term mortality in patients with radiation-associated coronary artery disease treated with percutaneous coronary intervention.
        Circ Cardiovasc Interv. 2016; 9

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