Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: implications for contemporary practice

Controversies in the Management of ST-Segment Elevation Myocardial Infarction: Transradial Versus Transfemoral Approach

This article discusses the controversies surrounding the use of transradial versus transfemoral approaches in the management of patients with ST-segment elevation myocardial infarction, beginning with a review of the benefits of transradial percutaneous coronary intervention (PCI) in this population. The unanswered questions about the mechanism underlying the mortality benefit of transradial PCI are discussed, concluding with recommendations for safe and effective strategies for adoption of the transradial approach to optimize outcomes in these high-risk patients.

Antithrombotic Approaches in Acute Coronary Syndromes: Optimizing Benefit vs Bleeding Risks

It is estimated that in the United States, each year, approximately 620,000 persons will experience an acute coronary syndrome and approximately 70% of these will have non-ST-elevation acute coronary syndrome. Cardiovascular disease still accounts for 1 of every 3 deaths in the United States, and there is an urgent need to improve the prognosis of patients presenting with acute coronary syndrome. Cardiovascular mortality and ischemic complications are common after acute coronary syndrome, and the advent of newer antithrombotic therapies has reduced ischemic complications, but at the expense of greater bleeding. The new antithrombotic agents also raise the challenge of choosing between multiple potential therapeutic combinations to minimize recurrent ischemia without a concomitant increase in bleeding, a decision that often varies according to an individual patient's relative propensity for ischemia versus hemorrhage. In this review, we will synthesize the available information to arm health care providers with the contemporary knowledge on antithrombotic therapy and individualize treatment decisions.

Prevention of post-operative bleeding in hemostatic compromised patients using native porcine collagen fleeces-retrospective study of a consecutive case series

INTRODUCTION

Various anticoagulant therapy regimes bear the risk of postsurgical bleeding events after dental extractions. Local hemostyptic measures, e.g., collagen fleeces, are applied by surgeons to prevent such bleedings. No standard protocol in prevention of bleeding events has met general acceptance among surgeons yet.

PURPOSE

The purpose of this retrospective study was to determine if post-operative bleeding can be prevented by suturing native collagen fleeces into extraction wounds immediately after teeth removal, regardless what anticoagulant regime is performed.

METHODS

A total of 741 extraction units were removed from 200 consecutive in-ward patients with or without alternation of different anticoagulant therapy regimes. Anti-vitamin K agents were the most prescribed drugs (n = 104, 52 %), followed by Acetylsalicylate (ASS) (n = 78, 39 %). Nineteen (9.5 %) patients received a dual anti-platelet therapy. Out of 104 patients receiving an anti-vitamin K agent (phenprocoumon), 84 patients were bridged, 20 patients continued to their anticoagulant therapy without alterations. Following careful tooth extraction, extraction sockets were filled using a native type I and III porcine collagen sponge (Collacone, Botiss Biomaterials, Berlin), supported by single and mattress sutures for local hemostasis. Post-operative bleeding events were rated according to their clinical relevance.

RESULTS

In the post-operative phase, 8 out of 200 consecutively treated patients experienced a post-operative bleeding event. All of them had been designated for a long-term anti-vitamin K therapy (p ≤ 0.05), and extractions were performed under a heparin bridging regime (n = 6) or an uninterrupted anti-vitamin K agent therapy (n = 2). No bleeding events occurred in patients with ASS 100 therapy or low-dose LMWH therapy (p ≤ 0.05), or in patients with dual anti-platelet therapy (0 out of 24). None of the bleeding events put patients' health at risk or required systemic intervention.

CONCLUSION

Sufficiently performed local hemostyptic measures, like the application of collagen fleeces in combination with atraumatic surgery, bears a great potential for preventing heavy bleeding events in hemostatic compromised patients, regardless of their anticoagulant therapy.

Impact of diabetes on bleeding events in ST-elevation myocardial infarction patients after urgent percutaneous coronary intervention: A retrospective cohort study

Patients with diabetes mellitus (DM) have more ischemic events and a decreased survival rate after percutaneous coronary intervention (PCI) than non-DM patients. However, it is unknown whether short-term or long-term bleeding events are associated with DM. We aimed to determine the impact of DM on mortality and bleeding events in ST-elevation myocardial infarction (STEMI) patients after urgent PCI.This retrospective cohort study included 435 STEMI patients who had undergone urgent PCI between 2010 and 2013, comprising 97 DM patients and 338 non-DM patients. The primary outcomes were the 30-day bleeding and 30-day mortality rates. The median follow-up period was 2 years. Data regarding patient demographics, peri-PCI medication, and invasive procedures were compared between DM and non-DM patients. Multivariate logistic regression was applied to estimate the association between DM and bleeding events. Kaplan-Meier curves were calculated to elucidate the survival rate.Compared with non-DM patients, DM patients with STEMI had a higher incidence of left ventricular ejection fraction <40% (17.6% vs 4.2%, P < 0.05), Killip class >II (11.3% vs 3.8%, P < 0.05), and smoking (44.3% vs 63.0%, P < 0.05). Similar peri-PCI medication and invasive procedures were administered in the 2 groups. The incidence of 30-day bleeding events was significantly higher for DM patients than non-DM patients (6.2% vs 0.9%, P < 0.05). A multivariate analysis showed that DM was strongly associated with 30-day bleeding events after adjusting for confounders. DM patients had significant increased mortality rates at both the 30-day and 2-year end points.DM was an independent predictor for an increased risk of 30-day bleeding events and correlated with increased 30-day and 2-year mortality rates in STEMI patients with PCI. Our study has significant clinical implications for risk stratification before the application of urgent PCI.

Radial Versus Femoral Access for Coronary Interventions Across the Entire Spectrum of Patients With Coronary Artery Disease: A Meta-Analysis of Randomized Trials

OBJECTIVES

The aim of this study was to provide a quantitative appraisal of the effects on clinical outcomes of radial access for coronary interventions in patients with coronary artery disease (CAD).

BACKGROUND

Randomized trials investigating radial versus femoral access for percutaneous coronary interventions have provided conflicting evidence. No comprehensive quantitative appraisal of the risks and benefits of each approach is available across the whole spectrum of patients with stable or unstable CAD.

METHODS

The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for randomized trials comparing radial versus femoral access for coronary interventions. Data were pooled by meta-analysis using a fixed-effects or a random-effects model, as appropriate. Pre-specified subgroup analyses according to clinical presentation, in terms of stable CAD, non-ST-segment elevation acute coronary syndromes, or ST-segment elevation myocardial infarction were performed.

RESULTS

Twenty-four studies enrolling 22,843 participants were included. Compared with femoral access, radial access was associated with a significantly lower risk for all-cause mortality (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.59 to 0.87; p = 0.001, number needed to treat to benefit [NNTB] = 160), major adverse cardiovascular events (OR: 0.84; 95% CI: 0.75 to 0.94; p = 0.002; NNTB = 99), major bleeding (OR: 0.53; 95% CI: 0.42 to 0.65; p < 0.001; NNTB = 103), and major vascular complications (OR: 0.23; 95% CI: 0.16 to 0.35; p < 0.001; NNTB = 117). The rates of myocardial infarction or stroke were similar in the 2 groups. Effects of radial access were consistent across the whole spectrum of patients with CAD for all appraised endpoints.

CONCLUSIONS

Compared with femoral access, radial access reduces mortality and MACE and improves safety, with reductions in major bleeding and vascular complications across the whole spectrum of patients with CAD.

Medicolegal implications of radial and femoral access for coronary angiography and intervention in 2016: Focus on retroperitoneal hemorrhage

BACKGROUND AND OBJECTIVES

Retroperitoneal hemorrhage is a rare but serious complication of transfemoral approach (TFA) and TFA percutaneous coronary intervention (PCI). Radial approach for coronary angiography and intervention (transradial approach, TRA) is associated with lower access site complications and reduced blood transfusion rates. Retroperitoneal bleeding has not been described with TRA. This study sought to evaluate the relationship between femoral access for coronary angiography (TFA) and PCI-induced retroperitoneal hemorrhage and the resulting medical litigation in the United States.

METHODS

From 342 lawsuit claim records identified in LexisNexis database search, 17 cases of TFA and TFAPCI-related retroperitoneal hemorrhage decided between 1995 and 2015 were included in the study. Claims were thoroughly reviewed and information about the date the case was decided, patient outcome, the plaintiff, the defendant, the claim, and the trial outcome were extracted.

RESULTS

The most common filled claim was medical malpractice (53% of the cases), followed by wrongful death (18%) and review of the Commissioner's decision to deny the application for supplemental security income (12%). Forty-seven percent of the cases were won by the defense, 29% by the plaintiff, and 24% were remanded for a new trial. In 82% of the cases, physicians were sued, but only 14% of the cases were won by the plaintiff. In 59% of the claims, the patient died; however, 70% of those cases were decided in favor of the defending physician and hospital.

CONCLUSION

Retroperitoneal hemorrhage is an uncommon complication of TFA and TFA PCI and is associated with high mortality rates. Physicians should able to identify this complication early and address it in a timely manner based on the applicable standard of care. TRA and TRA PCI is a reliable alternative and may potentially reduce medicolegal liability related to access site choice.

Comparative resource utilization and costs for patients with acute coronary syndrome managed with percutaneous coronary intervention and treated with clopidogrel or prasugrel

PURPOSE

Results of a study of bleeding events and other inhospital outcomes with the use of clopidogrel versus prasugrel in patients with acute coronary syndrome (ACS) managed with percutaneous coronary intervention (PCI) are reported.

METHODS

Demographic and clinical data on adults hospitalized for ACS, managed with PCI, and treated with clopidogrel or prasugrel during a two-year period were extracted from a large hospital claims database. Bleeding rates, hospital length of stay (LOS), and total hospital costs during the index hospitalization were evaluated.

RESULTS

The study sample consisted of 75,297 patients who received clopidogrel and 9,477 who received prasugrel. The unadjusted bleeding rates were 5.7% with clopidogrel use and 3.2% with prasugrel use (p < 0.0001). After propensity score stratification to adjust for selection bias, rates of bleeding events were not significantly different between clopidogrel- and prasugrel-treated patients (odds ratio, 0.90; 95% confidence interval [CI], 0.80-1.02; p = 0.0949). The adjusted mean ± S.D. hospital LOS was 0.22 day lower (95% CI, 0.15-0.28; p < 0.001) with the use of prasugrel versus clopidogrel, and adjusted total mean hospital costs were $375 less for prasugrel-treated patients (p = 0.003).

CONCLUSION

After adjustments for demographic and clinical characteristics, rates of inhospital bleeding in patients who received prasugrel and those who received clopidogrel were not significantly different. The adjusted analyses showed that the mean hospital LOS was shorter and total mean hospital costs were lower for patients treated with prasugrel.

Red cell distribution width in anemic patients undergoing transcatheter aortic valve implantation

AIM: To determine the impact of red blood cell distribution width on outcome in anemic patients undergoing transcatheter aortic valve implantation (TAVI).

METHODS: In a retrospective single center cohort study we determined the impact of baseline red cell distribution width (RDW) and anemia on outcome in 376 patients with aortic stenosis undergoing TAVI. All patients were discussed in the institutional heart team and declined for surgical aortic valve replacement due to high operative risk. Collected data included patient characteristics, imaging findings, periprocedural in hospital data, laboratory results and follow up data. Blood samples for hematology and biochemistry analysis were taken from every patient before and at fixed intervals up to 72 h after TAVI including blood count and creatinine. Descriptive statistics were used for patient’s characteristics. Kaplan-Meier survival curves were used for time to event outcomes. A recursive partitioning regression and classification was used to investigate the association between potential risk factors and outcome variables.

RESULTS: Mean age in our study population was 81 ± 6.1 years. Anemia was prevalent in 63.6% (n = 239) of our patients. Age and creatinine were identified as risk factors for anemia. In our study population, anemia per se did influence 30-d mortality but did not predict longterm mortality. In contrast, a RDW > 14% showed to be highly predictable for a reduced short- and longterm survival in patients with aortic valve disease after TAVI procedure.

CONCLUSION: Age and kidney function determine the degree of anemia. The anisocytosis of red blood cells in anemic patients supplements prognostic information in addition to that derived from the WHO-based definition of anemia.

Effects of P2Y12 receptor inhibition with or without aspirin on hemostatic system activation: a randomized trial in healthy subjects

ESSENTIALS: In acute coronary syndromes, dual antiplatelet therapy inhibits platelets but confers a bleeding risk. Healthy male volunteers received clopidogrel or ticagrelor plus aspirin or clopidogrel or ticagrelor alone. The decrease in β-thromboglobulin in shed blood was comparable after single and dual antiplatelet therapy. We hypothesize that patients with acute coronary syndromes may not require dual antiplatelet therapy.

BACKGROUND

Dual antiplatelet therapy with a P2Y12 inhibitor and aspirin is standard in acute coronary syndromes. Dual antiplatelet therapy causes more bleeding than single antiplatelet therapy with a P2Y12 inhibitor.

OBJECTIVES

To compare the effects of dual and single antiplatelet therapies on hemostatic system activation.

PATIENTS/METHODS

In a randomized, parallel-group, double-blind, placebo-controlled study, 44 healthy volunteers received clopidogrel (600 mg, then 150 mg d(-1) ) and aspirin (100 mg d(-1) ) or placebo for 7 days; An additional 44 volunteers received single-dose ticagrelor (180 mg) and aspirin (300 mg) or placebo. β-Thromboglobulin (β-TG [IU L(-1) ]) and prothrombin fragment 1.2 (f1.2 [nmol L(-1) ]) were measured in blood obtained from bleeding time incisions. Data are given as geometric mean ratio (GMR [95% confidence interval]) to describe the differences in the first 2 h and as mean differences (Δ [95% confidence interval]) in area under the curve (AUC) to discriminate differences in effects over the total observation time.

RESULTS

Clopidogrel plus aspirin and clopidogrel plus placebo reduced β-TG by a GMR of 0.51 (0.42-0.63) and 0.54 (0.46-0.64) at 2 h. Ticagrelor plus aspirin and ticagrelor plus placebo decreased β-TG by a GMR of 0.38 (0.26-0.57) and 0.47 (0.31-0.72). Ticagrelor plus aspirin and ticagrelor plus placebo reduced f1.2 by a GMR of 0.58 (0.45-0.75) and 0.55 (0.38-0.80); clopidogrel did not. Over 24 h, no difference in β-TG occurred between clopidogrel plus aspirin and clopidogrel plus placebo (ΔAUC = -2.9 [-9.9 to 4.1]) or between ticagrelor plus aspirin and ticagrelor plus placebo (ΔAUC = -3.5 [-11.8 to 4.7]). No difference in f1.2 occurred between clopidogrel plus aspirin and clopidogrel plus placebo (ΔAUC = -4.2 [-10.2 to 1.8]) or between ticagrelor plus aspirin and ticagrelor plus placebo (ΔAUC = -3.6 [-10.9 to 3.7]).

CONCLUSIONS

P2Y12 inhibitor monotherapy and dual antiplatelet therapy inhibit hemostatic system activation to a comparable extent.

A Safety Evaluation of Cangrelor in Patients Undergoing PCI

INTRODUCTION

Dual antiplatelet therapy with aspirin and an oral ADP P2Y12 receptor antagonist is the standard-of-care for treatment of patients undergoing percutaneous coronary intervention (PCI). However, oral P2Y12 receptor antagonists have several limitations, including inter- and intra-individual response variability, drug-drug interactions, slow onset and offset of action and delayed platelet inhibition in high-risk clinical settings, such as patients with ST-segment elevation myocardial infarction.

AREAS COVERED

Cangrelor is an intravenous, direct-acting, reversible, potent P2Y12 receptor antagonist. It rapidly achieves near complete platelet inhibition and has a very short half-life and a fast offset of action. We conducted a systematic review searching PubMed/MEDLINE for pharmacodynamic/pharmacokinetic studies and clinical trials in which cangrelor was investigated, published from any time up to November 1(st) 2015. For clinical trials, those investigating cangrelor in the setting of PCI were considered for discussion.

EXPERT OPINION

Cangrelor is approved by drug regulating authorities worldwide as adjunctive antithrombotic therapy for the full spectrum of patients undergoing PCI, not pre-treated with a P2Y12 receptor inhibitor and not with intent to receive a glycoprotein IIb/IIIa inhibitor. Its unique pharmacological properties and its favorable safety and efficacy profile make it an attractive treatment strategy, especially in clinical settings where immediate platelet inhibition is required.

The outcomes of intra-aortic balloon pump usage in patients with acute myocardial infarction: a comprehensive meta-analysis of 33 clinical trials and 18,889 patients

BACKGROUND

The effects of intra-aortic balloon pump (IABP) usage in patients with acute myocardial infarction remain controversial. This study sought to evaluate the outcomes of IABP usage in these patients.

METHODS

Medline, EMBASE, and other internet sources were searched for relevant clinical trials. The primary efficacy endpoints (in-hospital, midterm, and long-term mortality) and secondary endpoints (reinfarction, recurrent ischemia, and new heart failure in the hospital) as well as safety endpoints (severe bleeding requiring blood transfusion and stroke in-hospital) were subsequently analyzed.

RESULTS

Thirty-three clinical trials involving 18,889 patients were identified. The risk of long-term mortality in patients suffering from acute myocardial infarction was significantly decreased following IABP use (odds ratio [OR] 0.66, 95% confidence interval [CI]: 0.48-0.91, P=0.010). Both in-hospital and midterm mortality did not differ significantly between the IABP use group and no IABP use group (in-hospital: OR 0.87, 95% CI: 0.59-1.28, P=0.479; midterm: OR 1.12, 95% CI: 0.53-2.38, P=0.768). IABP insertion was not associated with the risk reduction of reinfarction, recurrent ischemia, or new heart failure. However, IABP use increased the risk of severe bleeding requiring blood transfusion (OR 2.05, 95% CI: 1.29-3.25, P=0.002) and stroke (OR 1.71, 95% CI: 1.04-2.82, P=0.035). In the thrombolytic therapy and cardiogenic shock subgroups, reduced mortality rates following IABP use were observed.

CONCLUSION

IABP insertion is associated with feasible benefits with respect to long-term survival rates in patients suffering from acute myocardial infarction, particularly those suffering from cardiogenic shock and receiving thrombolytic therapy, but at the cost of higher incidence of severe bleeding and stroke.

Impact of the age of stored blood on trauma patient mortality: a systematic review

BACKGROUND

The impact of the age of stored red blood cells on mortality in patients sustaining traumatic injuries requiring transfusion of blood products is unknown. The objective of this systematic review was to identify and describe the available literature on the use of older versus newer blood in trauma patient populations.

METHODS

We searched PubMed, Embase, Lilac and the Cochrane Database for published studies comparing the transfusion of newer versus older red blood cells in adult patients sustaining traumatic injuries. Studies included for review reported on trauma patients receiving transfusions of packed red blood cells, identified the age of stored blood that was transfused and reported patient mortality as an end point. We extracted data using a standardized form and assessed study quality using the Newcastle-Ottawa Scale.

RESULTS

Seven studies were identified (6780 patients) from 3936 initial search results. Four studies reported that transfusion of older blood was independently associated with increased mortality in trauma patients, while 3 studies did not observe any increase in patient mortality with the use of older versus newer blood. Three studies associated the transfusion of older blood with adverse patient outcomes, including longer stay in the intensive care unit, complicated sepsis, pneumonia and renal dysfunction. Studies varied considerably in design, volumes of blood transfused and definitions applied for old and new blood..

CONCLUSION

The impact of the age of stored packed red blood cells on mortality in trauma patients is inconclusive. Future investigations are warranted.

Efficacy and safety of antithrombotic regimens after coronary intervention in patients on oral anticoagulation: Traditional and Bayesian meta-analysis of clinical trials

OBJECTIVE

To perform a systematic review and meta-analysis to assess the efficacy and safety of diverse antithrombotic regimens in patients on long-term anticoagulation after percutaneous coronary intervention (PCI).

METHODS

After searching electronic database (up to 27 June 2015), we included trials comparing dual antiplatelet therapy (aspirin plus clopidogrel), oral anticoagulant (OAC) plus clopidogrel, OAC plus aspirin, or triple therapy (OAC with clopidogrel and aspirin). Efficacy outcomes were major adverse cardiovascular event (MACE), ischemic stroke, myocardial infarction (MI), and all-cause mortality; safety outcomes included major bleeding and any bleeding. We conducted both traditional and Bayesian network meta-analysis, computing pooled odds ratio (OR) with 95% confidence intervals (CI) to compare diverse antithrombotic therapies simultaneously.

RESULTS

Eighteen trials were included in the quantitative analysis. OAC plus clopidogrel and triple therapy were associated with a lower risk of MACE, ischemic stroke, MI and all-cause mortality compared with dual antiplatelet or OAC plus aspirin regimens. OAC plus clopidogrel was ranked the most efficacious option without an increase in bleeding episodes. However, triple therapy improved the efficacy outcomes at the expense of increasing hemorrhage. For the initial short-term outcomes, OAC plus clopidogrel inconclusively reduced the risk of MACE and had a significantly lower risk of any bleeding.

CONCLUSIONS

OAC plus clopidogrel may be the optimal antithrombotic therapy in patients on oral anticoagulation undergoing PCI, which has equal or better efficacy outcomes without increasing the rates of bleeding episodes. Moreover, we found initial triple therapy to be unnecessary as it increased the risk of bleeding.

Radial Versus Femoral Access in Invasively Managed Patients With Acute Coronary Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Studies in patients with acute coronary syndrome (ACS) undergoing invasive management showed conflicting conclusions regarding the effect of access site on outcomes.

PURPOSE

To summarize evidence from recent, high-quality trials that compared clinical outcomes occurring with radial versus femoral access in invasively managed adults with ACS.

DATA SOURCES

English-language publications in MEDLINE, EMBASE, and Cochrane databases between January 1990 and August 2015.

STUDY SELECTION

Randomized trials of radial versus femoral access in invasively managed patients with ACS.

DATA EXTRACTION

Two investigators independently extracted the study data and rated the risk of bias.

DATA SYNTHESIS

Of 17 identified randomized trials, 4 were high-quality multicenter trials that involved a total of 17 133 patients. Pooled data from the 4 trials showed that radial access reduced death (relative risk [RR], 0.73 [95% CI, 0.59 to 0.90]; P = 0.003), major adverse cardiovascular events (RR, 0.86 [CI, 0.75 to 0.98]; P = 0.025), and major bleeding (RR, 0.57 [CI, 0.37 to 0.88]; P = 0.011). Radial procedures lasted slightly longer (standardized mean difference, 0.11 minutes) and had higher risk for access-site crossover (6.3% vs. 1.7%) than did femoral procedures.

LIMITATION

Heterogeneity in outcomes definitions and potential treatment modifiers across studies, including operator experience in radial procedures and concurrent anticoagulant regimens.

CONCLUSION

Compared with femoral access, radial access reduces mortality, major adverse cardiovascular events, and major bleeding in patients with ACS undergoing invasive management.

PRIMARY FUNDING SOURCE

None. (PROSPERO registration number: CRD42015022031).

Low On-Treatment Platelet Reactivity Predicts Long-Term Risk of Bleeding After Elective PCI

BACKGROUND

Bleeding after percutaneous coronary interventions (PCI) is an important complication with impact on prognosis.

AIM

To evaluate the predictive value of enhanced platelet responsiveness to dual antiplatelet therapy with aspirin and clopidogrel, for bleeding, after elective PCI.

METHODS AND RESULTS

We performed multiple electrode aggregometry (MAE) platelet functional tests induced by arachidonic acid (ASPI) and adenosine-diphosphate (ADP) before PCI, and 24 hours after PCI, in 481 elective PCI patients who were followed-up for an average of 15.34 ± 7.19 months. Primary end point was the occurrence of any bleeding, while ischemic major adverse cardiovascular event (MACE) was a secondary endpoint. The incidence of total, BARC ≤ 2, and BARC ≥ 3 bleeding, according to BARC classification, was 19, 18, and 1%, respectively. Groups with any, and BARC ≤ 2 bleeding, had a lower average value of MAE ADP test after 24 hours, compared to the group without bleeding: 45.30 ± 18.63 U versus 50.99 ± 19.01 U; P = 0.005; and 45.75 ± 18.96 U versus 50.99 ± 18.99 U; P = 0.01; respectively. Female gender (HR 2.11; CI 1.37-3.25; P = 0.001), previous myocardial infarction (HR 0.56; CI 0.37-0.85; P = 0.006), lower body mass (HR 0.78; CI 0.62-0.98; P = 0.03), and MAE ADP test after 24 hours (HR 0.75; CI 0.61-0.93; P = 0.009) were the independent predictors for any bleeding by Cox univariate analysis. After adjustment, MAE ADP test after 24 hours, was the only independent predictor for any (HR 0.7; CI 0.56-0.87; P = 0.002), and BARC ≤ 2 (HR 0.71; CI 0.56-0.89; P = 0.003) bleeding, by Cox multivariate analysis.

CONCLUSION

MAE ADP test before and after PCI, was associated with any, and BARC ≤ 2 bleeding after elective PCI.

Access site practice and procedural outcomes in relation to clinical presentation in 439,947 patients undergoing percutaneous coronary intervention in the United kingdom

OBJECTIVES

This study sought to determine the relationships among access site practice, clinical presentation, and procedural outcomes in a large patient population.

BACKGROUND

Transradial access (TRA) has been associated with improved patient outcomes in selected populations in randomized trials. It is unclear whether these outcomes are achievable in clinical practice.

METHODS

Using the BCIS (British Cardiovascular Intervention Society) database, we investigated outcomes for percutaneous coronary intervention procedures undertaken between 2007 and 2012 according to access site practice. Patients were categorized as stable, non-ST-segment elevation acute coronary syndrome (NSTEACS) and ST-elevation acute coronary syndrome (STEACS). The impact of access site on 30-day mortality, major adverse cardiac events, bleeding, and arterial access site complications was studied.

RESULTS

Data from 210,260 TRA and 229,687 transfemoral access procedures were analyzed. Following multivariate analysis, TRA was independently associated with a reduction in bleeding in all presenting syndromes (stable odds ratio [OR]: 0.24, p < 0.001; NSTEACS OR: 0.35, p < 0.001; STEACS OR: 0.47, p < 0.001) as well as access site complications (stable OR: 0.21, p < 0.001; NSTEACS OR: 0.19; STEACS OR: 0.16, p < 0.001). TRA was associated with reduced major adverse cardiac events only in patients with unstable syndromes (stable OR: 1.08, p = 0.25; NSTEACS OR: 0.72, p < 0.001; STEACS OR: 0.70, p < 0.001). TRA was associated with improved outcomes compared with a transfemoral access (TFA) with a vascular closure device in a propensity matched cohort.

CONCLUSIONS

In this large study, TRA is associated with reduced percutaneous coronary intervention-related complications in all patient groups and may reduce major adverse cardiac events and mortality in ACS patients. TRA is superior to transfemoral access with closure devices. Use of TRA may lead to important patient benefits in routine practice. TRA should be considered the preferred access site for percutaneous coronary intervention.

The comparative efficacy of bivalirudin is markedly attenuated by use of radial access: insights from Blue Cross Blue Shield of Michigan Cardiovascular Consortium

AIM

The purpose of our study was to evaluate the relative impact of bivalirudin on bleeding outcomes associated with trans-radial interventions (TRI) in real world practice.

METHODS AND RESULTS

Data for patients undergoing percutaneous coronary intervention (PCI) between January 2010 and March 2014 at the 47 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) were utilized. Propensity matching was used within cohorts defined by access site. The impact of bivalirudin use on in-hospital outcomes was evaluated with Fisher's exact tests. Among patients undergoing trans-femoral interventions (TFI), use of bivalirudin was associated with a reduction in bleeding compared with both glycoprotein IIb/IIIa inhibitors (GPI; 1.67 vs. 3.46%, absolute risk reduction (ARR) 1.79%, odds ratio, OR, 0.47, confidence interval, CI, 0.41-0.54, number needed to treat, NNT 56, P < 0.001) and heparin (1.26 vs. 1.76%, ARR 0.5%, OR 0.71, CI 0.61-0.82, NNT 197, P < 0.001). Among patients undergoing TRI, there was a more modest absolute reduction in bleeding with bivalirudin compared with GPI (0.79 vs. 1.41%, ARR 0.62%, OR 0.56, CI 0.34-0.90, NNT 161, P = 0.016) and no difference in bleeding compared with heparin (0.46 vs. 0.46%, OR 1, CI 0.54-1.84, P = 1).

CONCLUSION

Bivalirudin is markedly efficacious in reducing bleeding in patients undergoing TFI. The reduction in bleeding associated with bivalirudin use is minimal to absent in patients undergoing TRI. Given its lower cost and comparable outcomes, heparin should be the preferred anticoagulation strategy in those undergoing radial PCI.

Comparison of quality-of-life measures after radial versus femoral artery access for cardiac catheterization in women: Results of the Study of Access Site for Enhancement of Percutaneous Coronary Intervention for Women quality-of-life substudy

BACKGROUND

In the SAFE-PCI for Women trial, patient preference for radial access for future procedures was greater than for femoral access. We sought to assess whether radial or femoral access impacts formal measures of quality-of-life (QOL) among women undergoing cardiac catheterization.

METHODS

We assessed QOL using European quality of life-5 dimensions (EQ-5D) and EQ visual analog scale (EQ-VAS) scores among 304 women randomized to radial or femoral arteriotomy in the SAFE-PCI for Women trial at sites with QOL substudy approval. Patient surveys were administered at baseline, hospital discharge, and 30 days (for percutaneous coronary intervention patients).

RESULTS

Women randomized to both treatments had similar EQ-5D index and EQ-VAS scores at baseline, hospital discharge, and 30-day follow-up. After adjustment for baseline scores, there was no effect of assigned treatment on EQ-5D (discharge 0.004; 95% CI -0.03 to 0.04; 30 days -0.03; 95% CI -0.09 to 0.02) or EQ-VAS (discharge -1.31; 95% CI -4.74 to 2.12; 30 days -2.10; 95% CI -8.92 to 4.71) scores. At discharge, 60.5% versus 63.5% (P = .60) of patients in radial and femoral groups were free from access site pain; at 30 days, rates were 85.7% versus 77.6% (P = .30), respectively. Patient preference for the same access strategy for repeat procedures was greater in the radial versus femoral group (77.2% vs 26.8%; P < .0001).

CONCLUSIONS

Using established QOL instruments, we did not measure any difference in QOL or functional status according to access site strategy in women undergoing cardiac catheterization, yet patient preference for the radial approach was significantly greater. Other factors influencing patient choice for radial access should be investigated.

Coronary artery disease in patients undergoing TAVI--why not to treat

The management of coronary artery disease in the context of severe aortic stenosis in patients at increased surgical risk is an increasingly relevant problem in the transcatheter aortic valve implantation (TAVI) era. We review the current data on percutaneous coronary intervention (PCI) in TAVI patients and discuss how it has impacted upon our decision making, advocating that pre-TAVI revascularisation is not necessarily required.

Comparative efficacy and safety of the left versus right radial approach for percutaneous coronary procedures: a meta-analysis including 6870 patients

The radial approach is widely used in the treatment of patients with coronary artery disease. We conducted a meta-analysis of published results on the efficacy and safety of the left and right radial approaches in patients undergoing percutaneous coronary procedures. A systematic search of reference databases was conducted, and data from 14 randomized controlled trials involving 6870 participants were analyzed. The left radial approach was associated with significant reductions in fluoroscopy time [standardized mean difference (SMD)=-0.14, 95% confidence interval (CI)=-0.19 to -0.09; P<0.00001] and contrast volume (SMD=-0.07, 95%CI=-0.12 to -0.02; P=0.009). There were no significant differences in rate of procedural failure of the left and the right radial approaches [risk ratios (RR)=0.98; 95%CI=0.77-1.25; P=0.88] or procedural time (SMD=-0.05, 95%CI=0.17-0.06; P=0.38). Tortuosity of the subclavian artery (RR=0.27, 95%CI=0.14-0.50; P<0.0001) was reported more frequently with the right radial approach. A greater number of catheters were used with the left than with the right radial approach (SMD=0.25, 95%CI=0.04-0.46; P=0.02). We conclude that the left radial approach is as safe as the right radial approach, and that the left radial approach should be recommended for use in percutaneous coronary procedures, especially in percutaneous coronary angiograms.

Antithrombotic therapy in the anticoagulated patient undergoing percutaneous coronary intervention with coronary stenting

PURPOSE OF REVIEW

Despite being the subject of extensive research, the optimal antithrombotic therapy for patients on chronic oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) with stent implantation is still unknown. This review presents the latest data regarding this much-debated topic.

RECENT FINDINGS

Dual therapy, with clopidogrel (a P2Y12 inhibitor) and OAC, may be an alternative to triple therapy, which usually consists of aspirin and clopidogrel in addition to OAC, in terms of improving clinical outcomes in patients on chronic OAC following PCI with stent implantation. With the arrival of new, safer nonvitamin K antagonists oral anticoagulants (NOACs), the combination of NOAC and clopidogrel may also be an option for replacing triple therapy. In contrast to clopidogrel, combining the more potent P2Y12 inhibitors (prasugrel and ticagrelor) with OAC may only be considered in certain specific circumstances.

SUMMARY

Patients on chronic OAC undergoing PCI with stent implantation require triple therapy. However, triple therapy is controversial, because it increases the risk of bleeding. With the introduction of prasugrel, ticagrelor and NOACs, the question arises which P2Y12 inhibitor to choose as part of the triple therapy regime and how NOACs combine with antiplatelet agents when treating patients undergoing PCI.

Antithrombotic Regimens for Patients Taking Oral Anticoagulation After Coronary Intervention: A Meta-analysis of 16 Clinical Trials and 9,185 Patients

The optimal antithrombotic regimen remains controversial in patients taking oral anticoagulation (OAC) undergoing coronary stenting. This study sought to compare efficacy and safety outcomes of triple therapy (OAC, aspirin, and clopidogrel) vs dual therapy (clopidogrel with aspirin or OAC) in these patients. We hypothesize OAC plus clopidogrel could be the optimal regimen for patients with indications for OAC receiving stent implantation. Medline, the Cochrane Library, and other Internet sources were searched for clinical trials comparing the efficacy and safety of triple vs dual therapy for patients taking OAC after coronary stenting. Sixteen eligible trials including 9185 patients were identified. The risks of major adverse cardiac events (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 0.82‐1.39, P = 0.65), all‐cause mortality (OR: 0.98, 95% CI: 0.76‐1.27, P = 0.89), myocardial infarction (OR: 1.01, 95% CI: 0.77‐1.31, P = 0.97), and stent thrombosis (OR: 0.91, 95% CI: 0.49‐1.69, P = 0.75) were similar between triple and dual therapy. Compared with dual therapy, triple therapy was associated with a reduced risk of ischemic stroke (OR: 0.57, 95% CI: 0.35‐0.94, P = 0.03) but with higher major bleeding (OR: 1.52, 95% CI: 1.11‐2.10, P = 0.01) and minor bleeding (OR: 1.59, 95% CI: 1.05‐2.42, P = 0.03). Subgroup analysis indicated there were similar ischemic stroke and major bleeding outcomes between triple therapy and therapy with OAC plus clopidogrel. Treatment with OAC and clopidogrel was associated with similar efficacy and safety outcomes compared with triple therapy. Triple therapy could be replaced by OAC plus clopidogrel without any concern about additional risk of thrombotic events.

Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice

Red blood cell (RBC) transfusion guidelines correctly promote a general restrictive transfusion approach for anemic hospitalized patients. Such recommendations have been derived from evaluation of specific patient populations, and it is important to recognize that engaging a strict guideline approach has the potential to incur harm if the clinician fails to provide a comprehensive review of the patient’s physiological status in determining the benefit and risks of transfusion. We reviewed the data in support of a restrictive or a more liberal RBC transfusion practice, and examined the quality of the datasets and manner of their interpretation to provide better context by which a physician can make a sound decision regarding RBC transfusion therapy. Reviewed studies included PubMed-cited (1974 to 2013) prospective randomized clinical trials, prospective subset analyses of randomized studies, nonrandomized controlled trials, observational case series, consecutive and nonconsecutive case series, and review articles. Prospective randomized clinical trials were acknowledged and emphasized as the best-quality evidence. The results of the analysis support that restrictive RBC transfusion practices appear safe in the hospitalized populations studied, although patients with acute coronary syndromes, traumatic brain injury and patients at risk for brain or spinal cord ischemia were not well represented in the reviewed studies. The lack of quality data regarding the purported adverse effects of RBC transfusion at best suggests that restrictive strategies are no worse than liberal strategies under the studied protocol conditions, and RBC transfusion therapy in the majority of instances represents a marker for greater severity of illness. The conclusion is that in the majority of clinical settings a restrictive RBC transfusion strategy is cost-effective, reduces the risk of adverse events specific to transfusion, and introduces no harm. In anemic patients with ongoing hemorrhage, with risk of significant bleeding, or with concurrent ischemic brain, spinal cord, or myocardium, the optimal hemoglobin transfusion trigger remains unknown. Broad-based adherence to guideline approaches of therapy must respect the individual patient condition as interpreted by comprehensive clinical review.

Underutilization of Radial Access in Patients Undergoing Percutaneous Coronary Intervention for ST-Segment–Elevation Myocardial Infarction

Background—

The purpose of this study was to evaluate the frequency and temporal trends in use of transradial access (TRA) for percutaneous coronary intervention (PCI) in ST-segment–elevation myocardial infarction (STEMI). The use of TRA has been associated with less bleeding and improved clinical outcomes in patients undergoing PCI for STEMI.

Methods and Results—

The frequency of TRA compared with transfemoral access for patients undergoing PCI for STEMI or other indications (non–ST-segment–elevation myocardial infarction, unstable angina, and non–acute coronary syndrome) in The Blue Cross Blue Shield of Michigan Cardiovascular Consortium database between 2010 and 2013 was evaluated. Propensity matching was used to assess the relationship of TRA with in-hospital clinical end points of major bleeding, transfusion, and death. The TRA cohort of patients was stratified into deciles based on their predicted bleeding risk and compared with PCI indication. Of 122 728 PCI procedures, 17 912 (14.6%) were via TRA. Among patients with STEMI cases, 8.3% of the PCI cases were performed via TRA. The use of TRA increased over the study period although the growth was slower for STEMI than for other indications, P <0.001. The use of TRA for PCI in STEMI was associated with a lower rate of bleeding (11.7% versus 20.0%; P <0.001) and vascular complications (0.7% versus 2.6%; P =0.001), but no mortality difference (1.25% versus 2.33%; P =0.175). There was a strong negative association between the predicted risk of bleeding and the use of TRA ( P <0.001).

Conclusions—

The use of radial access for PCI in STEMI is increasing but at a slower pace than for patients with other indications. TRA was associated with a reduction in bleeding and transfusion, but there is a strong negative correlation between the predicted risk of bleeding and actual use of TRA in STEMI.

Transradial Primary Percutaneous Coronary Intervention

Despite advances in antithrombotic and antiplatelet therapy, bleeding complications remain an important cause of morbidity and mortality in patients with acute ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Many bleeding events are related to the access site. Transradial access (TRA) PPCI is associated with significant reduction in bleeding and vascular complications and reduced cardiac mortality compared with the transfemoral approach (TFA). High-risk patients might particularly benefit from TRA. Radial skills providing procedural times and success rates comparable with those of the TFA are strongly recommended before using this technique in the STEMI PPCI setting.

Precision medicine to improve use of bleeding avoidance strategies and reduce bleeding in patients undergoing percutaneous coronary intervention: prospective cohort study before and after implementation of personalized bleeding risks

OBJECTIVE

To examine whether prospective bleeding risk estimates for patients undergoing percutaneous coronary intervention could improve the use of bleeding avoidance strategies and reduce bleeding.

DESIGN

Prospective cohort study comparing the use of bleeding avoidance strategies and bleeding rates before and after implementation of prospective risk stratification for peri-procedural bleeding.

SETTING

Nine hospitals in the United States.

PARTICIPANTS

All patients undergoing percutaneous coronary intervention for indications other than primary reperfusion for ST elevation myocardial infarction.

MAIN OUTCOME MEASURES

Use of bleeding avoidance strategies, including bivalirudin, radial approach, and vascular closure devices, and peri-procedural bleeding rates, stratified by bleeding risk. Observed changes were adjusted for changes observed in a pool of 1135 hospitals without access to pre-procedural risk stratification. Hospital level and physician level variability in use of bleeding avoidance strategies was examined.

RESULTS

In a comparison of 7408 pre-intervention procedures with 3529 post-intervention procedures, use of bleeding avoidance strategies within intervention sites increased with pre-procedural risk stratification (odds ratio 1.81, 95% confidence interval 1.44 to 2.27), particularly among higher risk patients (2.03, 1.58 to 2.61; 1.41, 1.09 to 1.83 in low risk patients, after adjustment for control sites; P for interaction = 0.05). Bleeding rates within intervention sites were significantly lower after implementation of risk stratification (1.0% v 1.7%; odds ratio 0.56, 0.40 to 0.78; 0.62, 0.44 to 0.87, after adjustment); the reduction in bleeding was greatest in high risk patients. Marked variability in use of bleeding avoidance strategies was observed across sites and physicians, both before and after implementation.

CONCLUSIONS

Prospective provision of individualized bleeding risk estimates was associated with increased use of bleeding avoidance strategies and lower bleeding rates. Marked variability between providers highlights an important opportunity to improve the consistency, safety, and quality of care. Study registration Clinicaltrials.gov NCT01383382.

Influence of Access, Anticoagulant, and Bleeding Definition on Outcomes of Primary Percutaneous Coronary Intervention: Early Experience of an US Academic Center

Background We aimed to carry out comparison of different bleeding avoidance strategies in doing primary percutaneous coronary intervention (PPCI) using either radial or femoral as access of choice and either bivalirudin or unfractionated heparin as anticoagulant of choice. In this analysis, we analyzed the influence of major bleeding definition on bleeding outcomes as well. Methods We did a retrospective analysis of 139 patients with ST-segment elevation myocardial infarction (STEMI) who had PPCI in our academic center from January 2010 till October 2013. The primary outcome at 30 days was a composite of death from any cause or stent thrombosis or non-coronary artery bypass grafting (CABG) related major bleeding (CathPCI Registry definition) and secondary outcomes were individual components of primary outcome and the hospital length of stay. Results There was no significant difference among different access/anticoagulant combinations with regards to primary outcome (22% in radial/bivalirudin vs. 5% in radial/heparin vs. 17% in femoral/bivalirudin vs. 28% in femoral/heparin group; p = 0.2) as well as its individual components except the hospital length of stay (2.56 vs. 3 vs. 3.97 vs. 4.4 days each; p < 0.0001). The overall rate of major bleeding was 11.5%. When we use HORIZON-AMI bleeding definition, it went up to 25 % due to one particular component (p < 0.004). Conclusions This single center observational study doing PPCI did not show any superiority of one bleeding avoidance strategy over others with regard to primary outcome and its individual components except the hospital length of stay. It also shows the importance of bleeding definition on bleeding outcomes.