Curriculum in CardiologyIncidence and correlates of major bleeding after percutaneous coronary intervention across different clinical presentations
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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Cited by (20)
Development and Implementation of an In-Hospital Bleeding Risk Model for Percutaneous Coronary Intervention
2021, Cardiovascular Revascularization MedicineCitation Excerpt :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
2017, Cardiovascular Revascularization MedicineCitation Excerpt :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 CardiologyCitation Excerpt :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
2015, Revista Brasileira de Cardiologia InvasivaCitation Excerpt :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
2015, International Journal of CardiologyCitation Excerpt :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].