Elsevier

American Heart Journal

Volume 168, Issue 3, September 2014, Pages 248-255
American Heart Journal

Curriculum in Cardiology
Incidence and correlates of major bleeding after percutaneous coronary intervention across different clinical presentations

https://doi.org/10.1016/j.ahj.2014.05.018Get rights and content

Background

Bleeding after percutaneous coronary intervention (PCI) is identified as a strong predictor for adverse events, including mortality. This study aims to compare the incidence and correlates of post-PCI bleeding across different clinical presentations.

Methods

The study included 23,943 consecutive PCI patients categorized according to their clinical presentation: stable angina pectoris (n = 6,741), unstable angina pectoris (UAP) (n = 5,215), non–ST-segment elevation myocardial infarction (NSTEMI) (n = 8,418), ST-segment elevation myocardial infarction (STEMI) (n = 2,721), and cardiogenic shock (CGS) (n = 848).

Results

Severity of clinical presentation was associated with a greater use of preprocedural anticoagulation, glycoprotein IIb/IIIa inhibitors, and intraaortic balloon pump (IABP). TIMI-defined major bleeding increased with increasing severity of clinical presentation: stable angina pectoris, 0.7%; UAP, 1.0%; NSTEMI, 1.6%; STEMI, 4.6%; and CGS, 13.5% (P < .001). On multivariable analysis, CGS (odds ratio [OR], 4.67; 95% CI [2.62-8.34]), STEMI (OR, 3.39; 95% CI [2.07-5.55]), and NSTEMI (OR, 2.00; 95% CI [1.29-3.10]) remained correlated with major bleeding even after adjusting for baseline and procedural differences, whereas UAP did not. The multivariable model also identified the use of IABP, female gender, congestive heart failure, no prior PCI, increased baseline hematocrit, and increased procedure time as correlates for major bleeding.

Conclusions

In patients undergoing PCI, the worsening severity of clinical presentation corresponds to an increase in incidence of post-PCI major bleeding. The increased risk with CGS, STEMI, and NSTEMI persisted despite adjusting for more aggressive pharmacotherapy and use of IABP. Careful attention to antithrombotic pharmacotherapy is warranted in this high-risk population.

Section snippets

Study population

This study consisted of patients who underwent PCI at MedStar Washington Hospital Center (Washington, DC) from 2001 to 2012. Patients were categorized by their indication for PCI according to clinical presentation: SAP, UAP, NSTEMI, STEMI, and CGS. Patients who received thrombolytics were excluded from this analysis. All patients provided written informed consent, and the study complied with the Declaration of Helsinki. The Institutional Review Boards at MedStar Washington Hospital Center and

Results

This study included 23,943 patients who underwent PCI; 6,741 patients (28.2%) presented with SAP; 5,215 (21.8%) presented with UAP; 8,418 (35.2%) presented with NSTEMI; 2,721 (11.4%) presented with STEMI; and 848 patients (3.5%) presented with CGS. Baseline characteristics are shown in Table I, and because of the large number of study patients, there were significant differences across the groups. Except for current smoking, STEMI patients had the fewest cardiovascular risk factors compared

Discussion

The main findings in our study are (1) TIMI major bleeding increased with the severity of clinical presentation, from SAP to CGS; (2) The need for blood transfusions and vascular complications increased with the severity of clinical presentation; (3) CGS, STEMI, and NSTEMI independently predicted TIMI major bleeding, whereas UAP did not; (4) IABP is a strong predictor of TIMI major bleed, whereas the use of different and multiple antithrombotics did not correlate with major bleed; and (5) The

Conclusions

In patients undergoing PCI, the worsening severity of clinical presentation corresponded to an increase in incidence of post-PCI major bleeding. The increased risk with CGS, STEMI, and NSTEMI persisted despite adjusting for more aggressive pharmacotherapy and use of IABP. Physicians should be cognizant of careful use of antithrombotic pharmacotherapy in an effort to minimize major bleeding in this high-risk population.

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      The incidence of post-PCI bleeding in our cohort (4.86%) was lower than the non-VA dataset used to develop the NCDR risk model (5.77%), potentially due to higher rates of elective PCI within the VA population. Multiple patient-level factors associated with bleeding in our model have been previously described by other studies, including chronic kidney disease, peripheral arterial disease, and indicators of clinical severity including cardiogenic shock and emergency/salvage procedural status [2,11,12,14,15]. Our dataset additionally includes pre-procedure laboratory values, allowing for the identification of INR and baseline hemoglobin as associated with bleeding.

    • Bivalirudin versus heparin in women undergoing percutaneous coronary intervention: A systematic review and meta-analysis of randomized clinical trials

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      This was also observed from NCDR data that showed a significant reduction in bleeding rates in women when strategies like bivalirudin and radial approach were used separately and in combination [35]. Despite prior studies showing increased bleeding risk in STEMI patients [36], in a subgroup analysis of our study including the 3 RCTs that exclusively enrolled STEMI patients [2,20,21], the previously shown benefit in reducing bleeding with bivalirudin, was no longer observed. This is mainly driven by the Bavarian Reperfusion AlternatiVes Evaluation (BRAVE 4) trial which showed a similar rate of major bleeding to bivalirudin compared to heparin arm.

    • Comparison of Propensity Score–Matched Analysis of Acute Kidney Injury After Percutaneous Coronary Intervention With Transradial Versus Transfemoral Approaches

      2017, American Journal of Cardiology
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      Primary source documents were obtained for all events and were adjudicated by physicians not involved in the procedures and unaware of the study objectives. We have previously described the definitions used for the present registry.7 In short, cardiogenic shock was defined as maximum systolic blood pressure <90 mm Hg for at least 30 minutes, unless treated with inotropes or intra-aortic balloon pump insertion regardless of the initial presenting diagnosis.

    • Risk factors for vascular access-related complications in patients undergoing early invasive strategy

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      The analysis of 10,676 procedures performed through radial access in a highly-experienced Italian center showed a rate of 0.41% of complications related to radial access, of which 0.10% were categorized as severe, including compartment syndrome, pseudoaneurysm, mycotic aneurysm, and hematoma with a decrease in hemoglobin > 3 g/dL, whose predictors were older age, female gender, and previous coronary artery bypass graft surgery.8 The clinical presentation of ACS in patients undergoing PCI translates into high risk of bleeding and ischemic outcomes, given the greater anatomical complexity of the lesions, the use of more aggressive antithrombotic therapy, including the use of IIb/IIIa glycoprotein inhibitors, and less frequent use of the radial approach and VCD to achieve hemostasis through the femoral access.9 Although an approximate 20% reduction in the rate of bleeding complications related to invasive coronary procedures was observed, it was due mainly to the use of drugs with better safety profile, demonstrating a gap in the adoption of other strategies aimed at reducing bleeding, especially those related to the vascular access use.10

    • Short and long-term mortality in women and men undergoing primary angioplasty: A comprehensive meta-analysis

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      However, even among this select cohort of patients women showed higher adjusted short-term mortality than men. Major bleeding is common in patients with AMI occurring in approximately 4–5% of patients undergoing PCI [69] and is an independent risk factor for mortality following AMI [70]. Post P-PCI women have higher rates of bleeding complications [7,9,22,31,39,53].

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