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| LETTER TO THE EDITOR |
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| Year : 2020 | Volume
: 4
| Issue : 1 | Page : 28-29 |
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Stroke and percutaneous coronary intervention: An overview
Jamir Pitton Rissardo, Ana Letícia Fornari Caprara
Department of Neurology; Department of Medicine, Federal University of Santa Maria, Santa Maria, Rio Grande Do Sul, Brasil
| Date of Submission | 06-Dec-2019 |
| Date of Acceptance | 28-Feb-2019 |
| Date of Web Publication | 17-Apr-2020 |
Correspondence Address:
Dr. Jamir Pitton Rissardo
Rua Roraima, Santa Maria, Rio Grande Do Sul
Brasil
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/hm.hm_79_19
How to cite this article:
Rissardo JP, Fornari Caprara AL. Stroke and percutaneous coronary intervention: An overview. Heart Mind 2020;4:28-9 |
Dear Editor,
We read the article entitled “On-Table Acute Ischemic Stroke during Primary Percutaneous Coronary Intervention (PCI)-Double Intra-Arterial Thrombolysis in a Young Patient: Uncommon Complication and “Double-Edged Sword' Management” on the esteemed “Heart and Mind” with great interest. Jariwala reported a case of a young male who was diagnosed with ST-segment elevation myocardial infarction (STEMI) within 2 h of onset. A PCI with tenecteplase was performed through the thromboaspiration catheter into the embolized area. After the subject started with a loss of power in the left upper limb and a cerebral angiography revealed a thrombus in the middle cerebral artery, intra-arterial thrombolysis was performed and the patient had a full recovery.[1]
Here, we would like to address some important topics from recently published articles that together with the study of Jariwala, could lead to a better comprehension of these associated comorbidities.
Alkhouli et al. studied the incidence, predictors, and outcomes of ischemic stroke after PCI. They retrospectively investigated the PCI subjects of the national inpatient sample, which is the largest publicly available administrative claims-based database, during 13 years. They encountered 8,289 (0.96%) strokes after 854,958 PCI for STEMI and 16,777 (0.81%) after 2,060,105 PCI for nonSTEMI. The main risk factors found were a history of atrial fibrillation, important carotid disease, cardiogenic shock, older age, and the procedure is done in an intermediate-to-small-volume center. Furthermore, the post-PCI stroke group showed a higher percentage of mortality and hospital stays. Their most interesting finding was about the incidence that when it was adjusted it was noted that the incidence of strokes increased for STEMI (0.6%–0.96%) and non-STEMI PCI (0.5%–0.6%) throughout the years. Thus, this finding could support the assumption that in the last decade, the PCI was performed for a major number of difficult cases that only were included in the selection after the development of new techniques.[2]
A recent systematic review by Gaudino et al. analyzed stroke after coronary artery bypass grafting (CABG) and PCI. They conclude that even though CABG has a higher perioperative risk for stroke than PCI, the individuals undergoing CABG have a lesser number of ischemic events and interventions. Moreover, these numbers appear to be directly proportional to coronary disease severity, such as subjects with diabetes mellitus and/or extensive multivessel disease. They also observed that a clear comparison between these two interventions and silent brain lesions or neurocognitive changes are lacking in the literature.[3]
A network meta-analysis anaortic off-pump CABG and PCI assessed the risk of the 30-day stroke risk. Their results included 63,837 patients, and they found that there was no difference in the 1-month stroke risk between the two procedures.[4] In this way, the Zhao et al.'s study showed a result different from the systematic review by Gaudino, but we believe that this probably occurred because Gaudino included all cases and Zhao et al. only were included anaortic technique.[3],[4] Therefore, we can assume that when a CABG is needed, maybe anaortic off-pump should be considered and can lead to better outcomes.[4]
A study from the Netherlands compared the efficacy and safety of dabigatran dual therapy versus warfarin triple therapy in individuals undergoing PCI with atrial fibrillation. More than two thousand participants were analyzed, and they showed that a bleeding event was lower in the dabigatran group independent of the modified HAS-BLED category. However, the protection for the development of stroke was the same.[5]
In sum, complications such as stroke are possible after a PCI. Its percentage is <1% and is significantly associated with cardiac rhythm and carotid disease. When it is feasible and many vessels are affected, the CABG should be considered. Furthermore, the anticoagulation period can be with new oral anticoagulants or warfarin.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Jariwala P. On-table acute ischemic stroke during primary PCI-double intra-arterial thrombolysis in a young patient: Uncommon complication and “double-edged sword” management. Heart Mind 2019;3:125.  [Full text] |
| 2. | Alkhouli M, Alqahtani F, Tarabishy A, Sandhu G, Rihal CS. Incidence, predictors, and outcomes of acute ischemic stroke following percutaneous coronary intervention. JACC Cardiovasc Interv 2019;12:1497-506. |
| 3. | Gaudino M, Angiolillo DJ, di Franco A, Capodanno D, Bakaeen F, Farkouh ME, et al. Stroke after coronary artery bypass grafting and percutaneous coronary intervention: Incidence, pathogenesis, and outcomes. J Am Heart Assoc 2019;8:e013032. |
| 4. | Zhao DF, Edelman JJ, Seco M, Bannon PG, Vallely MP. Thirty-day stroke risk after anaortic off-pump coronary artery bypass grafting versus percutaneous coronary intervention: A network meta-analysis. Heart Lung Circ 2019;28:117. |
| 5. | Lip GY, Mauri L, Montalescot G, Ozkor M, Vardas P, Steg PG, et al. Relationship of stroke and bleeding risk profiles to efficacy and safety of Dabigatran dual therapy versus warfarin triple therapy in atrial fibrillation after percutaneous coronary intervention: An ancillary analysis from the RE-DUAL PCI trial. Am Heart J 2019;212:13-22. |
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