Active cancer associated with higher mortality in acute coronary syndromes, PCI may mitigate risk

This is a systematic review and meta-analysis synthesizing evidence on patients with acute coronary syndromes (ACS) with and without active cancer. The analysis included a total sample size of 1,154,050 patients. The population comprised patients with ACS, some of whom had active cancer, compared to ACS patients without active cancer. The intervention or exposure was the presence of active cancer, with the comparator being ACS patients without active cancer. The primary outcome was mortality, and key secondary outcomes included myocardial infarction (MI) and bleeding risks.

The main results showed that in-hospital mortality was significantly higher in patients with cancer, with a relative risk (RR) of 2.56 (95% CI 1.07 to 6.15). Long-term mortality was also significantly higher in patients with cancer, with an RR of 3.55 (95% CI 1.71 to 7.36). For in-hospital mortality in patients not undergoing percutaneous coronary intervention (PCI), the RR was 4.02, indicating a significantly higher risk in cancer patients. However, for in-hospital mortality in patients undergoing PCI, the RR was 1.45, which was not significant. For long-term mortality without PCI, the RR was 6.13, showing an increased risk. For long-term mortality with PCI, the RR was 2.16, indicating a lower risk compared to those without PCI.

Key secondary outcomes included bleeding risk and MI risk. Bleeding risk was consistently higher in cancer patients, with an RR of 1.47. MI risk did not differ significantly between groups, with an RR of 1.01. Safety data, including adverse events, serious adverse events, discontinuations, and tolerability, were not reported in the input.

These results can be compared to prior landmark studies in this therapeutic area, though specific comparisons are not detailed in the input. The analysis highlights that patients with active cancer are often under-represented in clinical trials, which is a key methodological limitation and potential bias. This under-representation may affect the generalizability of findings.

Clinical implications from the practice relevance note suggest that invasive management, such as PCI, may be beneficial for this vulnerable population. The causality note indicates that active cancer is associated with increased mortality and bleeding, but the certainty note states that further prospective studies are required. The do not overstate note specifies that PCI appears to mitigate early mortality risk and reduce the magnitude of long-term mortality risk.

Key questions remain unanswered, including the optimal management strategies for ACS patients with active cancer, the role of PCI in different cancer types, and the mechanisms underlying the increased bleeding risk. The findings underscore the need for tailored approaches in this high-risk group.