Incidence, Predictors, and Prognostic Implications of Hospitalization for Late Bleeding After Percutaneous Coronary Intervention for Patients Older Than 65 Years

Use of thrombolysis in myocardial infarction risk score to predict bleeding complications in patients with unstable angina and non-ST elevation myocardial infarction undergoing percutaneous coronary intervention

Thrombolysis in myocardial infarction (TIMI) is a prognostic score developed for managing the high risk of cardiac events immediately after unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI). In Asian populations that have a higher rate of bleeding complications, data about TIMI score are lacking. Using a Japanese multicenter registry, we investigated the impact of utilizing TIMI score in UA/NSTEMI patients, focusing on bleeding complications. The TIMI score was calculated for 587 patients who underwent percutaneous coronary intervention (PCI) for UA/NSTEMI (2008-2010). They were classified into low-risk (TIMI score 0-2, N = 268, 45.6 %), intermediate-risk (TIMI score 3-4, N = 264, 45.0 %) and high-risk (TIMI score 5-7, N = 55, 9.4 %) groups; patient characteristics for each group were statistically analyzed. The patients in the higher TIMI score group were older (p < 0.001), had lower GFR (p = 0.021) and hemoglobin level after PCI (p < 0.001), and severe coronary disease pattern (p = 0.014 and p = 0.023, respectively, for left main and three-vessel disease). The TIMI score was significantly associated with requirement of blood transfusion (low-risk, moderate-risk, and high-risk groups: 1.1, 4.2, and 7.3 %, respectively; p = 0.021), and the incidence of access site bleeding (1.1, 2.7, and 5.5 %, p = 0.112). The TIMI score might aid in subjectively quantifying the risk of in-hospital complication rates such as access site bleeding.

Predictors of warfarin-induced bleeding in a South Indian cardiology unit

Objectives:

Warfarin-induced bleedingresults in increased morbidity and mortality and higher cost of healthcare. The objective of the study is to identify the predictors of warfarin-induced bleeding in the Cardiology Unit of a teaching hospital.

Materials and Methods:

A cross-sectional study was carried out for a period of six months in a tertiary care teaching hospital. A total of 235 patients were enrolled in the study, to identify the predictors of warfarin-induced bleeding. Only prescriptions with warfarin were selected for the study. The chi square test was used to find the association between demography and risk factors.

Results:

Out of 235 patients, 61 (25.95%) had developed warfarin-induced bleeding and the majority were in the age group of 41 – 61 years (60.65%), and it was also found to be higher in women (62.29%). The length of stay was > 14 days (65.57%) and the number of drugs prescribed was in the range of 6 – 12 (52.45%). Aspirin (40.98%), Heparin (36.06%), Clopidogrel (22.95%), and Streptokinase (14.75%) were the most common drugs involved, and other comorbid conditions like diabetes (37.70%), hypertension (32.78%), smoking (57.37%), and alcohol (32.78%) were found to be major predictors of warfarin-induced bleeding in this study. The severity of warfarin-induced most of the bleeding reactions were moderate (44.26%) and the most common site of bleeding was gastrointestinal system (34.42%).

Conclusion:

Predictors of warfarin-induced bleeding were found to be female gender, length of stay, number of medications, drugs like aspirin, heparin, and clopidogrel, and other comorbidities like smoking, alcohol, and hypertension.

Acute gastrointestinal bleeding after percutaneous coronary intervention

Bleeding from the GI tract is a commonly encountered clinical problem after percutaneous coronary intervention. The GI tract is likely to become the most commonly encountered site of bleeding as cardiologists adopt smaller access sheath sizes, percutaneous closure devices and a radial artery approach, further reducing access-site bleeding. To appropriately manage gastrointestinal bleeding in this setting, the clinician must strike a balance between arresting hemorrhage and preventing ischemic coronary complications. To do so, an appreciation of both cardiovascular and gastrointestinal issues is required. This review aims to provide the required knowledge, as well as a series of recommendations from our practice, to assist in the management of this potentially fatal complication.

Major adverse upper gastrointestinal events in patients with ST-segment elevation myocardial infarction undergoing primary coronary intervention and dual antiplatelet therapy

The aim of this study was to investigate the incidence of composite short-term and long-term major adverse upper gastrointestinal (UGI) events (MAUGIEs; defined as gastric ulcer, duodenal ulcer, gastroduodenal ulcer, or UGI bleeding) in patients with acute ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and routinely received dual-antiplatelet therapy. From May 2002 to September 2010, a total of 1,368 consecutive patients who experienced ST-segment elevation myocardial infarction and underwent primary percutaneous coronary intervention were prospectively enrolled in the study. The incidence of in-hospital UGI bleeding complications and composite MAUGIEs was 8.9% and 9.9%, respectively. The in-hospital mortality rate was significantly higher in patients with in-hospital MAUGIEs than in those without (p <0.001). Multivariate analysis showed that age, advanced Killip score (≥3), and respiratory failure were the strongest independent predictors of in-hospital composite MAUGIEs (all p <0.003). The cumulative composite of MAUGIEs after uneventful discharge in patients without adverse UGI events who continuously received dual-antiplatelet therapy for 3 to 12 months, followed by aspirin therapy, was 10.4% during long-term (mean 4.0 years) follow-up. In conclusion, the results of this study show a remarkably high incidence of composite short-term and long-term MAUGIEs in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and received routine dual-antiplatelet therapy. Age, advanced Killip score, and respiratory failure were significantly and independently predictive of in-hospital composite MAUGIEs.

Triple therapy in hospitalized patients: facts and controversies

The use of triple therapy (warfarin plus dual antiplatelet therapy) has increased in recent years due to an aging population with a higher risk for atrial fibrillation, as well as the increased use of coronary stents for acute coronary syndromes. Triple therapy confers a higher bleeding risk than either warfarin or dual antiplatelet therapy alone. However, warfarin alone is inadequate for patients with indications for triple therapy because of an unacceptable risk of stent thrombosis, and dual antiplatelet therapy is inferior to warfarin for the prevention of ischemic strokes in patients with atrial fibrillation, mechanical valves, or intraventricular thrombosis. Hospitalists face the challenge of balancing the aforementioned risks; the optimal management of these patients requires knowledge of the relevant literature and expertise. In this paper, we review the current literature on antiplatelet and anticoagulant combinations in patients with atrial fibrillation and coronary stents in order to improve adherence to published guidelines and to reduce the risk of bleeding.

Increased adverse events after percutaneous coronary intervention in patients with COPD: insights from the National Heart, Lung, and Blood Institute dynamic registry

BACKGROUND

Previous studies have demonstrated that patients with COPD are at higher risk for death after percutaneous coronary intervention (PCI), but other clinical outcomes and possible associations with adverse events have not been described.

METHODS

Using waves 1 through 5 (1999-2006) of the National Heart, Lung, and Blood Institute Dynamic Registry, patients with COPD (n = 860) and without COPD (n = 10,048) were compared. Baseline demographics, angiographic characteristics, and in-hospital and 1-year adverse events were compared.

RESULTS

Patients with COPD were older (mean age 66.8 vs 63.2 years, P < .001), more likely to be women, and more likely to have a history of diabetes, prior myocardial infarction, peripheral arterial disease, renal disease, and smoking. Patients with COPD also had a lower mean ejection fraction (49.1% vs 53.0%, P < .001) and a greater mean number of significant lesions (3.2 vs 3.0, P = .006). Rates of in-hospital death (2.2% vs 1.1%, P = .003) and major entry site complications (6.6% vs 4.2%, P < .001) were higher in pulmonary patients. At discharge, pulmonary patients were significantly less likely to be prescribed aspirin (92.4% vs 95.3%, P < .001), β-blockers (55.7% vs 76.2%, P < .001), and statins (60.0% vs 66.8%, P < .001). After adjustment, patients with COPD had significantly increased risk of death (hazard ratio [HR] = 1.30, 95% CI = 1.01-1.67) and repeat revascularization (HR = 1.22, 95% CI = 1.02-1.46) at 1 year, compared with patients without COPD.

CONCLUSIONS

COPD is associated with higher mortality rates and repeat revascularization within 1 year after PCI. These higher rates of adverse outcomes may be associated with lower rates of guideline-recommended class 1 medications prescribed at discharge.