Antiplatelet Discharge Regimens And Association With 30- And 1-year Stroke Or Death After Transcarotid Artery Revascularization
Hanaa Dakour-Aridi, MD1, Andres Fajardo, MD1, Raghu Motaganahalli, MD1, Michael Murphy, MD1, Akiko Tanaka, MD, PhD2, Kourosh Keyhani, DO3, Arash Keyhani, DO3, Shihuan K. Wang, MD3.
1Indiana University School of Medicine, Indianapolis, IN, USA, 2e University of Texas Health Science Center at Houston McGovern School of Medicine, Houston, TX, USA, 3Houston McGovern School of Medicine, Houston, TX, USA.
Objective: Current guidelines recommend dual-antiplatelets in the perioperative period after Transcarotid artery revascularization (TCAR). This study describes medication discharge regimens after TCAR and its association with 30-day and one-year outcomes.
Methods: Patients undergoing TCAR in the Vascular Quality Initiative were identified.188 patients (0.6%) with no discharge medication data were excluded. Follow up was available for 52.8% and 45.5% of the study cohort at 30-day and 1-year, respectively and was not significantly different between the study groups. Multivariate logistic and Cox-regression analyses were used to study the association between antiplatelet regimens and postoperative stroke/death outcomes, respectively.
Results: A total of 29614 patients were included.Of those,80.8% were discharged on dual antiplatelets,5.8% on a single antiplatelet agent with anticoagulation,9% on triple therapy and 4.4% were discharged on either a single antiplatelet agent or anticoagulation only. Baseline characteristics are shown in the Table. Patients discharged on a single antiplatelet agent+anticoagulation had higher rates of 30-day stroke/death (5.7%) compared to those on dual antiplatelet therapy (2.3%), triple therapy (3.7%) and those on other regimens (P<0.001). Compared to dual antiplatelet therapy, receiving single antiplatelet agent +anticoagulation was significantly associated with increased 30-day stroke/death (OR:1.92, 95%CI:1.35-2.72,P<0.001) and high-grade (>70%) restenosis (OR:1.95, 95%CI: 1.13-3.36,P=0.02) after multivariate adjustment. Other regimens (single antiplatelet only or anticoagulation only) were associated with 63% increase in the odds of 30-day stroke/death (OR:1.63, 95%CI: 1.02-2.59,P=0.04). At one year of follow-up, patients on single antiplatelet agent+anticoagulation had higher mortality and stroke/death [HR (95%CI):1.48 (1.16-1.88) and 1.36(1.05-1.76);P<0.05, respectively] compared with those on dual antiplatelets. Similarly, patients on other regimens had higher 1-year stroke/death rates [HR (95%CI):1.52(1.05-2.18),P=0.03].
Conclusion(s): 19.2% of VQI patients are not discharged on dual antiplatelet therapy after TCAR.Our analysis shows a significant increase in 30-day and 1-year stroke/death in patients discharged on a single antiplatelet agent with or without anticoagulation as well as those discharged on anticoagulation only. While this study does not offer complete follow-up information and does not evaluate bleeding risk, it highlights the importance of compliance to dual antiplatelet therapy after TCAR and the need for further follow-up studies to evaluate the safety of TCAR in different patient populations.
| Table 1. Baseline Characteristics | |||||
| Dual Antiplatelet (23941, 80.8%) | Single Antiplatelet + Anticoagulation (1719, 5.8%) | Triple therapy (2655, 9.0%) | Other (1299, 4.4%) | P-value | |
| Median Age in years, median (IQR) | 74 (67-79) | 77 (70-82) | 76 (70-81) | 74 (68-80) | <0.001 |
| Count (%) | Count (%) | Count (%) | Count (%) | ||
| Female Gender | 8964 (37.4) | 554 (32.2) | 806 (30.4) | 541 (41.7) | <0.001 |
| Non-White Race | 2419 (10.1) | 139 (8.1) | 181 (6.8) | 131 (10.1) | <0.001 |
| Symptomatic Status | 6123 (25.6) | 498 (29.0) | 734 (27.7) | 283 (21.8) | <0.001 |
| Hypertension | 21870 (91.4) | 1610 (93.7) | 2486 (93.7) | 1172 (90.2) | <0.001 |
| Diabetes | 9059 (37.8) | 719 (41.8) | 1125 (42.4) | 506 (39.0) | <0.001 |
| Coronary artery disease | 12139 (50.7) | 1090 (63.4) | 1698 (64.0) | 646 (49.7) | <0.001 |
| Congestive heart failure | 3507 (14.7) | 576 (33.5) | 869 (32.7) | 186 (14.3) | <0.001 |
| Chronic obstructive pulmonary disease | 5857 (24.5) | 473 (27.5) | 792 (29.8) | 336 (25.9) | <0.001 |
| Chronic kidney disease | 9052 (37.9) | 827 (48.2) | 1132 (42.7) | 523 (40.4) | <0.001 |
| Dialysis | 305 (1.3) | 42 (2.4) | 46 (1.7) | 19 (1.5) | <0.01 |
| Current Smoker | 5366 (22.4) | 251 (14.6) | 430 (16.2) | 289 (22.3) | <0.001 |
| Contralateral Occlusion | 2078 (9.0) | 119 (7.2) | 229 (9.0) | 123 (9.9) | 0.051 |
| Annual Physicians' Case Volume | |||||
| Low (<6 cases/yr) | 8309 (34.7) | 547 (31.8) | 914 (34.4) | 422 (32.5) | <0.001 |
| Medium (6-13 cases/yr) | 7707 (32.2) | 535 (31.1) | 915 (34.5) | 409 (31.5) | |
| High (>13 cases/yr) | 7925 (33.1) | 637 (37.1) | 826 (31.1) | 468 (36.0) | |
| Elective cases | 21341 (89.2) | 1478 (86.0) | 2332 (87.8) | 1140 (87.8) | <0.01 |
| Pre-stent dilatation | 20567 (89.2) | 1436 (87.7) | 2313 (90.1) | 1066 (86.2) | <0.01 |
| Post-stent dilatation | 9224 (38.8) | 703 (41.3) | 1011 (38.5) | 536 (42.3) | 0.02 |
| Non-Home discharge | 1301 (5.4) | 188 (10.9) | 233 (8.8) | 94 (7.2) | <0.001 |
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