Impact of Bleeding on Mortality After Percutaneous Coronary Intervention

Radial versus femoral access for primary percutaneous interventions in ST-segment elevation myocardial infarction patients: a meta-analysis of randomized controlled trials

OBJECTIVES

This study sought to determine the safety and efficacy of radial access compared with femoral access for primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Numerous randomized controlled trials, including several new studies, have compared outcomes of these approaches in the context of primary PCI for STEMI patients with inconclusive results.

METHODS

We performed a meta-analysis of randomized controlled trials to compare outcomes in STEMI patients undergoing radial versus femoral access for primary PCI. Primary outcomes were death and major bleeding evaluated at the longest available follow-up. Secondary outcomes included access site bleeding, stroke, and procedure time. Twelve studies (N = 5,055) were included. All trials were conducted in centers experienced with both approaches.

RESULTS

Compared with femoral approach, radial approach was associated with decreased risk of mortality (2.7% vs. 4.7%; odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.40 to 0.76; p < 0.001) and decreased risk of major bleeding (1.4% vs. 2.9%; OR: 0.51, 95% CI: 0.31 to 0.85; p = 0.01). Radial access was also associated with reduction in relative risk of access site bleeding (2.1% vs. 5.6%; OR: 0.35, 95% CI: 0.25 to 0.50; p < 0.001). Stroke risk was similar between both approaches (0.5% vs. 0.5%; OR: 1.07, 95% CI: 0.45 to 2.54; p = 0.87). The procedure time was slightly longer in the radial group than in the femoral group (mean difference: 1.52 min; 95% CI: 0.33 to 2.70, p = 0.01).

CONCLUSIONS

In STEMI patients undergoing primary PCI, the radial approach is associated with favorable outcomes and should be the preferred approach for experienced radial operators.

Impact of baseline hemorrhagic risk on the benefit of bivalirudin versus unfractionated heparin in patients treated with coronary angioplasty: a meta-regression analysis of randomized trials

BACKGROUND

Bivalirudin significantly reduces 30-day major and minor bleeding compared with unfractionated heparin (UFH), while resulting in similar or lower rates of ischemic events in both patients with stable and unstable coronary disease undergoing percutaneous coronary intervention. We performed a meta-analysis of randomized trials to evaluate the impact of bivalirudin compared with UFH, with or without glycoprotein IIb/IIIa receptor inhibitors (GPI), on the rates of mortality, myocardial infarction (MI), and major bleeding.

METHODS

We searched electronic databases for randomized controlled trials with >100 patients comparing bivalirudin (±provisional GPI) with UFH with either routine or provisional GPI in patients undergoing percutaneous coronary intervention. The principal efficacy end points were mortality and MI within 30 day, whereas major bleeding was the principal safety end point. We assessed the benefit of bivalirudin for each efficacy end point relative to the baseline bleeding risk, using the control (UFH) major bleeding rate as proxy for that risk.

RESULTS

A total of 12 randomized trials that enrolled 33,261 patients were included. Overall, there was no significant difference in mortality and MI between bivalirudin monotherapy and UFH (±GPI), whereas major bleeding was significantly lower with bivalirudin. Bivalirudin reduced major and minor bleeding across the entire bleeding risk spectrum.

CONCLUSIONS

Bivalirudin significantly reduces major and minor bleeding regardless of the estimated baseline hemorrhagic risk.

Major bleeding after percutaneous coronary intervention and risk of subsequent mortality: a systematic review and meta-analysis

OBJECTIVES

To examine the relationship between periprocedural bleeding complications and major adverse cardiovascular events (MACEs) and mortality outcomes following percutaneous coronary intervention (PCI) and study differences in the prognostic impact of different bleeding definitions.

METHODS

We conducted a systematic review and meta-analysis of PCI studies that evaluated periprocedural bleeding complications and their impact on MACEs and mortality outcomes. A systematic search of MEDLINE and EMBASE was conducted to identify relevant studies. Data from relevant studies were extracted and random effects meta-analysis was used to estimate the risk of adverse outcomes with periprocedural bleeding. Statistical heterogeneity was assessed by considering the I(2) statistic.

RESULTS

42 relevant studies were identified including 533 333 patients. Meta-analysis demonstrated that periprocedural major bleeding complications was independently associated with increased risk of mortality (OR 3.31 (2.86 to 3.82), I(2)=80%) and MACEs (OR 3.89 (3.26 to 4.64), I(2)=42%). A differential impact of major bleeding as defined by different bleeding definitions on mortality outcomes was observed, in which the REPLACE-2 (OR 6.69, 95% CI 2.26 to 19.81), STEEPLE (OR 6.59, 95% CI 3.89 to 11.16) and BARC (OR 5.40, 95% CI 1.74 to 16.74) had the worst prognostic impacts while HORIZONS-AMI (OR 1.51, 95% CI 1.11 to 2.05) had the least impact on mortality outcomes.

CONCLUSIONS

Major bleeding after PCI is independently associated with a threefold increase in mortality and MACEs outcomes. Different contemporary bleeding definitions have differential impacts on mortality outcomes, with 1.5-6.7-fold increases in mortality observed depending on the definition of major bleeding used.

Increased risk of minor bleeding and antiplatelet therapy cessation in patients with acute coronary syndromes and low on-aspirin platelet reactivity. A prospective cohort study

Bleeding negatively affects prognosis and adherence to antiplatelet therapy after acute coronary syndromes (ACSs). The potential association of on-aspirin platelet reactivity and bleeding is not established. We sought to determine whether low on-aspirin platelet reactivity (LAPR) is associated with bleeding events and antiplatelet therapy compliance in patients with ACSs receiving coronary stenting. On-aspirin platelet reactivity was measured by the VerifyNow™ Aspirin assay (Accumetrics Inc., San Diego, CA, USA) in 531 patients with ACS. Cut-offs for LAPR were calculated by receiver-operating characteristic curve (ROC) analysis. Bleeding was reported according to Bleeding Academic Research Consortium (BARC) definition. The endpoints were minor bleeding (BARC types 1 or 2), major bleeding (BARC types 3 or 5) and antiplatelet therapy cessation during 6-months follow-up. By ROC analysis the VerifyNow™ Aspirin assay was able to distinguish between patients with and without minor bleeding (area under the curve [AUC] 0.66, 95 % confidence interval [CI] 0.62-0.70, P < 0.0001) whereas major bleeding could not be predicted by the assay (AUC 0.54, 95 % CI 0.49-0.58, P = 0.473). By logistic regression, LAPR was associated with increased risk of minor bleeding (odds ratio [OR] 4.32, 95 % CI 2.78-6.71, P < 0.0001) but not major bleeding (OR 2.05, 95 % CI 0.83-5.06, P = 0.117). Antiplatelet therapy discontinuation was more frequent in patients with LAPR as compared to those with no LAPR (21.6 vs. 9.1 %, P = 0.0008). In conclusion, early point-of-care on-aspirin platelet reactivity testing in ACS may identify patients with increased risk of minor bleeding events and subsequent discontinuation of antiplatelet therapy. The possible impact of LAPR on major bleeding needs to be determined in larger trials.

In-hospital major bleeding and its clinical relevance in patients with ST elevation myocardial infarction treated with primary percutaneous coronary intervention

Advances in antithrombotic therapy for ST elevation myocardial infarction (STEMI) enhance the risk of bleeding. Therefore, the incidence, determinants, and prognostic implications of in-hospital major bleeding after primary percutaneous coronary intervention for STEMI were investigated. In 963 consecutive patients, the incidence of bleeding was evaluated according to commonly used classifications including Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA guidelines, Thrombolysis In Myocardial Infarction, Global Use of Strategies To Open coronary arteries, and Bleeding Academic Research Consortium. Multivariate regression analyses investigated determinants of bleeding and the relation between bleeding and 1-year all-cause mortality. Large variability in incidence existed depending on classification (1.3% to 21%). Female gender, heart rate, creatinine, multivessel disease, cardiogenic shock, and procedural failure were independently associated with bleeding. One-year mortality reached 10.2% in bleeders versus 2.0% in nonbleeders (p <0.001). Bleeding was independently associated with an increased risk of 1-year mortality (hazard ratio [HR] 2.41, p <0.017). Assessment of individual classifications confirmed the increased risk of mortality for Bleeding Academic Research Consortium (HR 2.27, p = 0.048), but not for Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA guidelines, Thrombolysis In Myocardial Infarction, and Global Use of Strategies To Open coronary arteries bleeding. Thrombotic events occurred more frequently in bleeders (5.8% vs 1.5%, p <0.001); however, bleeding remained independently related to mortality with a negligible reduction in HR (2.25, p = 0.028) after adjustment. In conclusion, in-hospital major bleeding was frequently observed after STEMI, but a widespread variation in incidence existed depending on the applied definition. Patient and procedural characteristics were related to bleeding, allowing identification of high-risk patients. In-hospital major bleeding was independently associated with 1-year all-cause mortality; however, not all bleeding classifications proved equally relevant to prognosis. The relation between bleeding and mortality was shown not to be driven by the higher rate of thrombotic events among bleeders.

The clinical and economic impact of bivalirudin for percutaneous coronary intervention

Bivalirudin (BVR) is a direct thrombin inhibitor used as an adjunctive antithrombotic agent in combination with aspirin and an ADP-receptor blocker in patients with acute coronary syndrome undergoing percutaneous coronary intervention. When compared to a strategy of heparin plus a glycoprotein IIb/IIIa inhibitor, BVR has been shown in a number of randomized clinical trials to be at least as effective at reducing ischemic endpoints and to have a consistently lower rate of bleeding complications. In addition, various economic analyses have shown it to be cost-effective compared to heparin plus a glycoprotein IIb/IIIa inhibitor and this, coupled with its proven clinical efficacy, has led to the incorporation of BVR into both EU and US clinical guidelines. Previous studies with BVR have mostly assessed its use in patients treated with aspirin and clopidogrel and further studies are ongoing to determine its role in combination with newer, more potent oral antiplatelet agents.

Incidence and implications of idiopathic thrombocytopenia following transcatheter aortic valve replacement with the Edwards Sapien(©) valves: a single center experience

OBJECTIVES

To determine the incidence and etiology of thrombocytopenia following transcatheter Aortic valve replacement (TAVR).

BACKGROUND

the use of TAVR in the United States has grown rapidly. Anecdotally, thrombocytopenia following TAVR with the Sapien valves has been observed, though little is known about this phenomenon.

METHODS

All patients treated with TAVR using a Sapien valve or who underwent isolated balloon aortic valvuloplasty (BAV) at Brigham and Women's Hospital from October 2009 through November 2012 were analyzed. Post-procedure thrombocytopenia severity was stratified as none (>150,000 cells/μL), mild (100-150,000), and moderate to severe (<100,000). Summary statistics and simple comparisons were evaluated. Linear regression models were used to identify patient or procedural factors associated with platelet count nadir.

RESULTS

112 TAVR and 105 BAV patients were analyzed. Following TAVR the prevalence of thrombocytopenia was 69% and the incidence of new thrombocytopenia was 45% compared to 37% and 17% respectively following BAV (P < 0.01). Similar results were found across all strata of thrombocytopenia severity. Post-TAVR platelet nadirs were greater by 1,840 cells/μL for each 1% increase in STS score (P = 0.03) and 670 cells/μL greater for each 1 mmHg increase in pre-TAVR mean aortic stenosis gradient. Among TAVR patients, thrombocytopenia appears to spontaneously resolve an average of 8 days post-procedure. No differences in clinical outcomes based on thrombocytopenia severity were observed except for an increased use of blood products (P = 0.05).

CONCLUSIONS

Thrombocytopenia following TAVR with the Edwards' Sapien valves is a frequent but generally self-limited process. The etiology of this phenomenon is unknown.

The bleeding risk score as a mortality predictor in patients with acute coronary syndrome

BACKGROUND

It is well known that the occurrence of bleeding increases in-hospital mortality in patients with acute coronary syndromes (ACS), and there is a good correlation between bleeding risk scores and bleeding incidence. However, the role of bleeding risk score as mortality predictor is poorly studied.

OBJECTIVE

The main purpose of this paper was to analyze the role of bleeding risk score as in-hospital mortality predictor in a cohort of patients with ACS treated in a single cardiology tertiary center.

METHODS

Out of 1655 patients with ACS (547 with ST-elevation ACS and 1118 with non-ST-elevation ACS), we calculated the ACUITY/HORIZONS bleeding score prospectively in 249 patients and retrospectively in the remaining 1416. Mortality information and hemorrhagic complications were also obtained.

RESULTS

Among the mean age of 64.3 ± 12.6 years, the mean bleeding score was 18 ± 7.7. The correlation between bleeding and mortality was highly significant (p < 0.001, OR = 5.296), as well as the correlation between bleeding score and in-hospital bleeding (p < 0.001, OR = 1.058), and between bleeding score and in-hospital mortality (adjusted OR = 1.121, p < 0.001, area under the ROC curve 0.753, p < 0.001). The adjusted OR and area under the ROC curve for the population with ST-elevation ACS were, respectively, 1.046 (p = 0.046) and 0.686 ± 0.040 (p < 0.001); for non-ST-elevation ACS the figures were, respectively, 1.150 (p < 0.001) and 0.769 ± 0.036 (p < 0.001).

CONCLUSIONS

Bleeding risk score is a very useful and highly reliable predictor of in-hospital mortality in a wide range of patients with acute coronary syndromes, especially in those with unstable angina or non-ST-elevation acute myocardial infarction.

Incidence and prognostic value of bleeding after percutaneous coronary intervention in patients older than 75 years of age

OBJECTIVES

We aimed to assess the impact of bleeding after percutaneous coronary intervention (PCI) on the outcome of patients >75 years of age.

BACKGROUND

Limited information exists on the impact of post-PCI bleeding on the outcome in elderly patients.

METHODS

This study included 3,255 patients >75 years of age. Bleeding events were assessed using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality.

RESULTS

Within 30 days after PCI, bleeding occurred in 501 patients (15.4%). Bleeding according to BARC was: class 1 (170 patients; 33.9%), class 2 (81 patients; 16.2%), class 3a (177 patients; 35.3%), class 3b (65 patients; 13.0%), class 3c (four patients; 0.8%), and class 4 (four patients; 0.8%). There were 201 deaths within the first year after PCI: 61 deaths (12.3%) among bleeders and 140 deaths (5.1%) among nonbleeders (adjusted hazard ratio = 2.03, 95% confidence interval [CI] 1.42-2.91, P < 0.001). Bleeding improved the discriminatory power of multivariable model for mortality prediction (P = 0.001). Female sex (adjusted odds ratio [OR] = 1.49 [1.17-1.88], P = 0.001) and reduced renal function (adjusted OR = 1.30 [1.04-1.63], P = 0.019 for each 30 ml/min decrease in the creatinine clearance) were independent associates of increased bleeding risk. Bivalirudin reduced the bleeding risk by 24% compared with unfractionated heparin and 33% compared with abciximab plus unfractionated heparin.

CONCLUSIONS

Post-PCI bleeding is an important prognostic factor in patients >75 years of age. The risk for bleeding in this age category is increased in women and patients with impaired renal function. Bleeding risk is reduced by bivalirudin.

Balance of Ischemia and Bleeding in Selecting an Antithrombotic Regimen

Complications after percutaneous coronary intervention (PCI) are of 2 types: ischemic and bleeding. This article provides strategies to individualize pharmacologic regimens after PCI based on periprocedural risk assessment. A practical method to assess whether a patient is at risk for ischemic or bleeding complications is the use of risk scores. Patients at a low risk of bleeding benefit from aggressive antithrombotic therapy. Patients at a high risk of bleeding benefit from selective use of antithrombotic agents. As a large number of antithrombotic agents are currently available, individualization of the antithrombotic drug regimes should be considered in every patient.

Management of patients with acute coronary syndromes in real-world practice in Italy: an outcome research study focused on the use of ANTithRombotic Agents: the MANTRA registry

BACKGROUND

Although outcomes of acute coronary syndromes (ACS) have greatly improved, bleeding is still an issue. Thus, this study aims to evaluate in-hospital management and outcomes of unselected patients with ACS focusing on antithrombotic therapies and bleeding.

METHODS AND RESULTS

From 22 April 2009 to 29 December 2010, 6394 consecutive Italian patients were prospectively enrolled and followed for 6 months. Most patients (55.3%) had non-ST-elevation (NSTE) ACS. Of the ST-elevation (STE) ACS patients, 79.8% received reperfusion (mainly mechanical). In-hospital and 6-month unadjusted total mortality rates were 4.2 and 7.8% for STE-ACS and 2.5 and 6.4% for NSTE-ACS, respectively. During hospitalization, TIMI major bleeding rate was 1.2% (1.4% STE-ACS and 1.1% NSTE-ACS, respectively) and TIMI minor bleeding was 3.1%. In-hospital and 6-month unadjusted total mortality rates were 3.1 and 6.7% for patients without bleeding, 1.5 and 8.6% for minor bleeding, and 19.0 and 26.6% for TIMI major bleeding, respectively (p<0.0001). Notably, TIMI major bleeding was one of the strongest predictors of the 6-month composite end point (death or reinfarction) (STE-ACS hazard ratio, HR, 2.86, 95% confidence interval, 95% CI, 1.57-5.23; NSTE-ACS HR, 2.71, 95% CI 1.52-4.80). Predictors of in-hospital TIMI major bleeding were weight (odds ratio, OR, 0.97, 95% CI 0.95-0.99), female gender (OR 1.80, 95% CI 1.09-2.96), history of peripheral vasculopathy (OR 2.95, 95% CI 1.83-4.78), switching anticoagulant therapy (OR 2.62, 95% CI 1.36-5.05), intra-aortic balloon pump implantation (OR 4.44, 95% CI 1.85-10.69), and creatinine ≥2 mg/dl on admission (OR 3.68, 95% CI 1.84-7.33).

CONCLUSIONS

Despite aggressive management, the rate of bleeding remains relatively low in an unselected ACS population. However, major bleeding adversely affects prognosis and physicians should tailor treatments to reduce it.

Bleeding after percutaneous coronary intervention in women and men matched for age, body mass index, and type of antithrombotic therapy

BACKGROUND

Factors underlying the increased risk of bleeding after percutaneous coronary intervention (PCI) in women compared with men remain incompletely understood.

METHODS

The study included 3,351 women and 3,351 men matched for age, body mass index, and type of antithrombotic therapy. Bleeding within the 30 days after PCI was defined using the Bleeding Academic Research Consortium criteria. The main outcome was 1-year mortality.

RESULTS

Bleeding occurred in 518 women and 354 men (15.5% vs 10.6%, odds ratio [OR] 1.55, 95% CI 1.34-1.79, P < .001). Severe (Bleeding Academic Research Consortium class ≥2) bleeds (9.4% vs 6.5%, P < .001) and access site bleeds (10.1% vs 5.4%, P < .001) were more common in women. After adjustment, female sex remained an independent correlate of any bleeding (adjusted OR 1.61 [1.35-1.92], P < .001) and access site (adjusted OR 2.00 [1.59-2.50], P < .001) but not of nonaccess site (adjusted OR 1.18 [0.91-1.54], P = .205) bleeding. There were 248 deaths: 32 deaths among men with bleeding versus 107 deaths among men with no bleeding (9.1% vs 3.6%, OR 2.68 [1.78-4.05], P < .001) and 40 deaths among women with bleeding vs 69 deaths among women with no bleeding (7.8% vs 2.5%, OR 3.35 [2.24-5.01], P < .001). No difference in mortality was observed among women and men who bled (P = .487). Bleeding was independently associated 1-year mortality (adjusted hazard ratio 2.18 [1.68-2.84], P < .001) with no bleeding-by-sex interaction (P = .439).

CONCLUSIONS

Despite matching for age, body mass index, and type of antithrombotic therapy, bleeding risk after PCI remained significantly higher in women than in men. Bleeding was associated with increased risk of 1-year mortality with no bleeding-by-sex interaction.

Prognostic significance of bleeding location and severity among patients with acute coronary syndromes

OBJECTIVES

This study sought to determine if there is an association between bleed location and clinical outcomes in acute coronary syndromes (ACS) patients.

BACKGROUND

The prognostic significance of bleeding location among ACS patients undergoing cardiac catheterization is not well known.

METHODS

We analyzed in-hospital bleeding events among 9,978 patients randomized in the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) study. Bleeding events were categorized by location as access site, systemic, surgical, or superficial, and severity was graded using the GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definition. We assessed the association of each bleeding location and severity with 6-month risk of death or myocardial infarction using a multicovariate-adjusted Cox proportional hazard model.

RESULTS

A total of 4,900 bleeding events were identified among 3,694 ACS patients with in-hospital bleeding. Among 4,679 GUSTO mild/moderate bleeding events, only surgical and systemic bleeds were associated with an increased risk of 6-month death or myocardial infarction (adjusted hazard ratio [HR]: 2.52 [95% confidence interval (CI): 2.16 to 2.94, and 1.40 [95% CI: 1.16 to 1.69], respectively). Mild/moderate superficial and access-site bleeds were not associated with downstream risk (adjusted HR: 1.17 [95% CI: 0.97 to 1.40], and 0.96 [95% CI: 0.82 to 1.12], respectively). Among 221 GUSTO severe bleeds, surgical bleeds were associated with the highest risk (HR: 5.27 [95% CI: 3.80 to 7.29]), followed by systemic (HR: 4.48 [95% CI: 2.98 to 6.72]), and finally access-site bleeds (HR: 3.57 [95% CI: 2.35 to 5.40]).

CONCLUSIONS

Among ACS patients who develop in-hospital bleeding, systemic and surgical bleeding are associated with the highest risks of adverse outcomes regardless of bleeding severity. Although the most frequent among bleeds, GUSTO mild/moderate access-site bleeding is not associated with increased risk. These data underscore the importance of strategies to minimize overall bleeding risk beyond vascular access site management.

BLEED-Myocardial Infarction Score: Predicting mid-term post-discharge bleeding events

AIM: To derive and validate a score for the prediction of mid-term bleeding events following discharge for myocardial infarction (MI).

METHODS: One thousand and fifty patients admitted for MI and followed for 19.9 ± 6.7 mo were assigned to a derivation cohort. A new risk model, called BLEED-MI, was developed for predicting clinically significant bleeding events during follow-up (primary endpoint) and a composite endpoint of significant hemorrhage plus all-cause mortality (secondary endpoint), incorporating the following variables: age, diabetes mellitus, arterial hypertension, smoking habits, blood urea nitrogen, glomerular filtration rate and hemoglobin at admission, history of stroke, bleeding during hospitalization or previous major bleeding, heart failure during hospitalization and anti-thrombotic therapies prescribed at discharge. The BLEED-MI model was tested for calibration, accuracy and discrimination in the derivation sample and in a new, independent, validation cohort comprising 852 patients admitted at a later date.

RESULTS: The BLEED-MI score showed good calibration in both derivation and validation samples (Hosmer-Lemeshow test P value 0.371 and 0.444, respectively) and high accuracy within each individual patient (Brier score 0.061 and 0.067, respectively). Its discriminative performance in predicting the primary outcome was relatively high (c-statistic of 0.753 ± 0.032 in the derivation cohort and 0.718 ± 0.033 in the validation sample). Incidence of primary/secondary endpoints increased progressively with increasing BLEED-MI scores. In the validation sample, a BLEED-MI score below 2 had a negative predictive value of 98.7% (152/154) for the occurrence of a clinically significant hemorrhagic episode during follow-up and for the composite endpoint of post-discharge hemorrhage plus all-cause mortality. An accurate prediction of bleeding events was shown independently of mortality, as BLEED-MI predicted bleeding with similar efficacy in patients who did not die during follow-up: Area Under the Curve 0.703, Hosmer-Lemeshow test P value 0.547, Brier score 0.060; low-risk (BLEED-MI score 0-3) event rate: 1.2%; intermediate risk (score 4-6) event rate: 5.6%; high risk (score ≥ 7) event rate: 12.5%.

CONCLUSION: A new bedside prediction-scoring model for post-discharge mid-term bleeding has been derived and preliminarily validated. This is the first score designed to predict mid- term hemorrhagic risk in patients discharged following admission for acute MI. This model should be externally validated in larger cohorts of patients before its potential implementation.

Sex-related effectiveness of bivalirudin versus abciximab and heparin in non-ST-segment elevation myocardial infarction

BACKGROUND

Female sex independently predicts bleeding risk after percutaneous coronary intervention (PCI). Bivalirudin is safer than abciximab plus heparin in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Thus, a greater benefit of bivalirudin in women would be expected.

METHODS

We performed a sex-based analysis of the patients with NSTEMI (n = 1,721, 399 women) enrolled in the ISAR-REACT 4 trial and randomized to receive bivalirudin or abciximab plus heparin. Main outcome was a 30-day composite of death, large recurrent myocardial infarction, urgent target vessel revascularization, or major bleeding. Secondary outcome was 1-year composite of death, myocardial infarction, or target vessel revascularization.

RESULTS

No difference in the main outcome was observed in groups with bivalirudin or abciximab plus heparin: 12.6% versus 15.5% (hazard ratio [HR] 0.81, 95% CI 0.48-1.37) among women and 10.6% versus 9.5% (HR 1.12, 95% CI 0.77-1.64) among men. Major bleeding occurred in 4.5% in the bivalirudin group versus 7.5% in the abciximab plus heparin group (HR 0.60, 95% CI 0.26-1.39) among women and 2.0% versus 3.8% (HR 0.52, 0.27-1.02) among men. At 1 year, the secondary outcome was observed in 24.1% in the bivalirudin group versus 28.7% in the abciximab plus heparin group among women, HR of 0.80 (95% CI 0.55-1.17), and in 20.6% and 19.0%, respectively, HR of 1.10 (95% CI 0.86-1.40) among men.

CONCLUSION

Despite a higher peri-PCI bleeding risk in women, bivalirudin is as effective as and safer than abciximab plus heparin in women and men with NSTEMI undergoing PCI.

Nuisance bleeding with prolonged dual antiplatelet therapy after acute myocardial infarction and its impact on health status

OBJECTIVES

The purpose of this study was to examine the incidence of nuisance bleeding after AMI and its impact on QOL.

BACKGROUND

Prolonged dual antiplatelet therapy (DAPT) is recommended after acute myocardial infarction (AMI) to reduce ischemic events, but it is associated with increased rates of major and minor bleeding. The incidence of even lesser degrees of post-discharge "nuisance" bleeding with DAPT and its impact on quality of life (QOL) are unknown.

METHODS

Data from the 24-center TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status) study of 3,560 patients, who were interviewed at 1, 6, and 12 months after AMI, were used to investigate the incidence of nuisance bleeding (defined as Bleeding Academic Research Consortium type 1). Baseline characteristics associated with "nuisance" bleeding and its association with QOL, as measured by the EuroQol 5 Dimension visual analog scale, and subsequent re-hospitalization were examined.

RESULTS

Nuisance (Bleeding Academic Research Consortium type 1) bleeding occurred in 1,335 patients (37.5%) over the 12 months after AMI. After adjusting for baseline bleeding and mortality risk, ongoing DAPT was the strongest predictor of nuisance bleeding (rate ratio [RR]: 1.44, 95% confidence interval [CI]: 1.17 to 1.76 at 1 month; RR: 1.89, 95% CI: 1.35 to 2.65 at 6 months; and RR: 1.39, 95% CI: 1.08 to 1.79 at 12 months; p < 0.01 for all comparisons). Nuisance bleeding at 1 month was independently associated with a decrement in QOL at 1 month (-2.81 points on EuroQol 5 Dimension visual analog scale; 95% CI: 1.09 to 5.64) and nonsignificantly toward higher re-hospitalization (hazard ratio: 1.20; 95% CI: 0.95 to 1.52).

CONCLUSIONS

Nuisance bleeding is common in the year after AMI, associated with ongoing use of DAPT, and independently associated with worse QOL. Improved selection of patients for prolonged DAPT may help minimize the incidence and adverse consequences of nuisance bleeding.

Characteristics and outcomes of patients with ST-segment elevation myocardial infarction excluded from the harmonizing outcomes with revascularization and stents in acute myocardial infarction (HORIZONS-AMI) trial

Randomized controlled trials assessing new drugs and devices tend to exclude subjects who are at greatest risk. The Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial incorporated broader inclusion criteria in an attempt to include a more representative spectrum of patients presenting with ST-segment elevation myocardial infarction (STEMI). To identify the differences between this modern trial and the real world, we analyzed the characteristics and outcomes of patients with STEMI who were screened but not enrolled at a high-volume recruiting center. Of 318 consecutive patients with STEMI who were screened, 200 (62.9%) were randomized, and 118 (37.1%) were excluded. The baseline characteristics and 30-day and 1-year clinical outcomes were compared in the 2 groups. The excluded patients had numerous high-risk features compared to those randomized, including being older (67.0 ± 12.8 vs 63.0 ± 11.4 years, p = 0.004), more often had had a previous MI (34.7% vs 8.0%, p <0.001), Killip class III-IV (27.4% vs 4.0%, p <0.001), and lower hemoglobin (13.4 ± 2.3 vs 14.8 ± 1.5 g/dl, p <0.001). The excluded patients had markedly greater 30-day and 1-year rates of all-cause mortality (17.4% vs 2.0%, p <0.001, and 27.6% vs 2.5%, p <0.001, respectively), major adverse cardiovascular events (death, MI, ischemia-driven target vessel revascularization, and stroke), major bleeding, and net adverse clinical events (major adverse cardiovascular events or major bleeding). On multivariate analysis, Killip class III-IV at presentation, age, left ventricular ejection fraction, and final Thrombolysis In Myocardial Infarction flow grade 3 were independent predictors of outcome. In conclusion, despite the broadened entry criteria of the HORIZONS-AMI trial, 37.1% of all patients presenting with STEMI at a center with a high rate of enrollment were judged to be ineligible and were excluded. The excluded patients had a significantly greater risk profile and markedly increased mortality and adverse events compared to the trial-eligible group.

Comparison of Three-year outcomes after primary percutaneous coronary intervention in patients with left ventricular ejection fraction <40% versus ≥ 40% (from the HORIZONS-AMI trial)

Left ventricular (LV) dysfunction and multivessel disease (MVD) have been associated with greater mortality after ST-segment elevation myocardial infarction. The aim of this study was to evaluate the impact of LV dysfunction and MVD in patients with ST-segment elevation myocardial infarctions treated with primary percutaneous coronary intervention (PCI). Patients from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial treated with primary PCI in whom baseline LV function was assessed using left ventriculography were included in this study. Early and late (3-year) outcomes were examined in groups of patients with reduced (<40%) and preserved (≥ 40%) LV ejection fractions (LVEFs), further stratified by the presence of MVD. A total of 2,430 patients were included. Patients with reduced LVEFs were older; were more likely to be women; were more likely to have histories of myocardial infarction, PCI, and heart failure; and were more likely to present in heart failure. Patients with reduced LVEFs had greater 30-day (8.9% vs 0.9%, hazard ratio 9.81, 95% confidence interval 5.23 to 18.42, p <0.0001) and 3-year (17.1% vs 3.7%, hazard ratio 5.03, 95% confidence interval 3.37 to 7.50, p <0.0001) mortality. Among patients with LVEFs <30% (n = 45), 30% to 40% (n = 157), 40% to 50% (n = 373), 50% to 60% (n = 659), and ≥ 60% (n = 1,196), 3-year mortality was 29.4%, 13.5%, 6.4%, 3.8%, and 2.9%, respectively (p for trend <0.0001). MVD was associated with greater mortality in patients with preserved but not reduced LVEFs. By multivariate analysis, LV dysfunction was the strongest predictor of 30-day and 3-year mortality. In conclusion, the presence of LV dysfunction as assessed on baseline left ventriculography in patients who undergo primary PCI in the contemporary era is a powerful predictor of early and late mortality, regardless of the extent of coronary artery disease.

Ticagrelor: a P2Y12 antagonist for use in acute coronary syndromes

Agents that inhibit platelet function are used routinely in the treatment and prevention of acute coronary syndromes. The main antiplatelet treatments used combine aspirin with one of the thienopyridine P2Y(12) antagonists, either clopidogrel or prasugrel. By blocking the synthesis of thromboxane A(2) in platelets and by blocking the effects of ADP, respectively, these agents reduce platelet activity, platelet aggregation and thrombus formation. Ticagrelor (marketed by AstraZeneca as Brilinta™ in the USA, and as Brilique(®) or Possia(®) in Europe) is a cyclopentyl-triazolo-pyrimidine, a new chemical class of P2Y(12) antagonist that is now approved for use in the wide spectrum of acute coronary syndromes. In this article we provide an overview of ticagrelor. We discuss the differences in mode of action compared with other P2Y(12) antagonists, examine its pharmacodynamic, pharmacokinetic and safety profile, and summarize the various clinical trials that have provided information on its efficacy in combination with aspirin. Ticagrelor appears to overcome some of the difficulties that have been encountered with other antiplatelet treatments, clopidogrel in particular.

The Use of Bivalirudin in ST-Segment Elevation Myocardial Infarction: Advantages and Limitations

The incidence of ST-segment elevation myocardial infarction (STEMI) is a common, albeit declining, manifestation of coronary heart disease. Significant improvements in cardiovascular outcomes and mortality in STEMI patients have occurred in recent years, reflecting evolution in the understanding of the pathophysiological mechanisms and therapeutic targets of this disease. Nonetheless, the risks of recurrent ischemia and bleeding complications in this population remain substantial. This review focuses on the adjunctive anticoagulant agents used in the management of STEMI. Major insights from the HORIZONS-AMI trial regarding the impact of bivalirudin on both hemorrhagic and ischemic outcomes in STEMI patients are discussed.

Adverse impact of bleeding and transfusion on the outcome post-transcatheter aortic valve implantation: insights from the Pooled-RotterdAm-Milano-Toulouse In Collaboration Plus (PRAGMATIC Plus) initiative

BACKGROUND

Little is known about the impact of bleeding and red blood cells transfusion (RBC) on the outcome post transcatheter aortic valve implantation (TAVI).

METHODS

Between November 2005 and August 2011, 943 consecutive patients underwent TAVI. Bleeding was assessed according to the Valve Academic Research Consortium definitions. Patients receiving RBC were compared to those not requiring transfusion.

RESULTS

Life-threatening and major bleedings occurred respectively in 13.9% and 20.9% of the patients, significantly more frequently in the RBC cohort. Vascular complications occurred in 23.2% of the patients. Major and minor vascular complications were more frequent in the RBC group: 19.3 vs 5.2%, P < .001; 15.3 vs 9%, P = .003, respectively. Thirty-day all-cause mortality was 7.2%. Of the overall cohort, 38.9% required RBC transfusion; those receiving at least 4 U of RBC had higher 30-day all-cause mortality than those receiving 1 to 4 U of RBC and those not requiring transfusion: 14.4%, vs 6.3% vs 6.3%, respectively, P = .008. By multivariate analysis, transfusion of RBC was associated with an increased 30-day and 1-year mortality. Major stroke and all stages of acute kidney injury were significantly more frequent in the RBC cohort.

CONCLUSIONS

Bleeding is frequent after TAVI, mainly driven by vascular complications. RBC transfusion was associated with increased mortality at 1 year and increased risk of major stroke and acute kidney injury. Specific scores are needed to identify the patients at higher risk for TAVI-related bleeding and RBC transfusion.

Clinical outcomes following stent thrombosis occurring in-hospital versus out-of-hospital: results from the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial

OBJECTIVES

The study sought to determine whether rapid access to medical care and reperfusion results in a better prognosis in patients with in-hospital compared with out-of-hospital stent thrombosis (ST) in patients with ST-segment elevation myocardial infarction (STEMI) in the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial.

BACKGROUND

Whether the prognosis of in-hospital and out-of-hospital ST are similar is uncertain, with conflicting data reported from prior studies.

METHODS

A total of 3,602 STEMI patients undergoing primary percutaneous coronary intervention (PCI) were randomized to bivalirudin (n = 1,800) versus unfractionated heparin (UFH) plus a glycoprotein IIb/IIIa inhibitor (GPI) (UFH+GPI; n = 1,802). Stents were implanted in 3,202 patients, 156 (4.9%) of whom developed Academic Research Consortium definite/probable ST during 3-year follow-up. We investigated the 1-year clinical outcomes after ST in 54 patients with in-hospital ST compared with 102 patients with out-of-hospital ST.

RESULTS

One year after the ST event, patients with in-hospital compared with out-of-hospital ST had significantly greater mortality (27.8% vs. 10.8%, p < 0.01); most deaths in both groups occurred within 1 week of the ST event. Patients with in-hospital ST also had higher rates of major bleeding (21.2% vs. 6.0%, p < 0.01), but a lower rate of myocardial infarction (56.6% vs. 77.5%, p < 0.01). Subgroup analysis within both in-hospital and out-of-hospital ST groups indicated that subacute ST had the highest mortality. By multivariable analysis, 1-year mortality was significantly increased in patients with in-hospital compared with out-of-hospital ST (adjusted hazard ratio: 4.62, 95% confidence interval: 1.98 to 10.77, p < 0.01). Additional correlates of increased mortality after an ST event included diabetes and randomization to UFH+GPI (vs. bivalirudin).

CONCLUSIONS

Following primary PCI for STEMI, more than one-third of all ST events during 3-year follow-up occurred during the index hospital phase. Mortality and major bleeding were significantly higher after in-hospital ST compared with out-of-hospital ST. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction; NCT00433966).

Atopaxar: a review of its mechanism of action and role in patients with coronary artery disease

Platelet activation and aggregation is a complex and key process in thrombus formation after the rupture of an atherosclerotic plaque, which can lead to an acute coronary syndrome. Aspirin, an irreversible inhibitor of thromboxane A2 synthesis, in combination with an inhibitor of P2Y12 ADP platelet receptors (clopidogrel, prasugrel or ticagrelor), represents the current standard of care of antiplatelet therapy for patients with acute coronary syndrome and in those patients undergoing percutaneous coronary intervention. Despite the benefit of these agents, the risk of thrombotic events and bleeding complications may still occur while on such antiplatelet treatment regimens, thus representing an important limitation. Thrombin is one of the most important platelet activators. The inhibition of thrombin-mediated platelet activation by means of protease-activated receptor-1 inhibitors represents an attractive therapeutic option for patients with atherothrombotic disease processes. This article provides an overview on atopaxar (E5555), an orally active protease-activated receptor-1 antagonist that has recently completed Phase II clinical investigation.

Management of acute coronary syndrome: achievements and goals still to pursue. Novel developments in diagnosis and treatment

Acute coronary syndromes contribute a substantial part of the global disease burden. To realize a reduction in mortality and morbidity, the management of patients with these conditions involves the integration of several different approaches. Timely delivery of appropriate care is a key factor, as the beneficial effect of reperfusion is greatest when performed as soon as possible. Innovations in antithrombotic therapy have also contributed significantly to improvements in the prevention of ischaemic complications. However, with the use of such treatment, an increase in the risk of bleeding is inevitable. Therefore, the greatest challenge is now to obtain an optimal balance between the prevention of ischaemic complications and the risk of bleeding. In this regard, identification of patients at highest risk of either one is essential.

Risk stratification and timing of revascularization: which patients benefit from early versus later revascularization?

In acute coronary syndromes, risk stratification is essential, particularly in patients without ST elevation, and is based upon clinical, electrocardiogram (ECG), and biological markers. Among them, recent and repeated attacks of angina, ST-segment deviation from baseline on the admission ECG as well as elevated markers of myonecrosis (particularly increased troponin levels), myocardial dysfunction (B-type natriuretic peptide [BNP]; N-terminal prohormone of BNP[NT-proBNP]), and inflammation (high-sensitivity C-reactive protein) are predictors of an adverse outcome. These variables can be incorporated into broader risk predictive scores, among which the TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores are the most widely used. Two general therapeutic strategies (routine invasive vs conservative or selective invasive) are employed in the treatment of non-ST-segment elevation acute coronary syndrome (NSTEACS). Evidence-based analysis and the current American College of Cardiology/American Heart Association/Society for Cardiac Angiography and Interventions clinical practice guidelines recommend an early invasive treatment strategy (8-24 h) for intermediate or high clinical risk patients with NSTEACS.

What is the optimal antithrombotic strategy in primary percutaneous coronary intervention?

PURPOSE OF REVIEW

Major bleeding in the setting of acute coronary syndromes and percutaneous coronary intervention has been associated with increased short-term and long-term risk for adverse cardiac events and mortality. Recent studies on antithrombotic agents in this setting have highlighted their differential impact on ischemic and hemorrhagic complications.

RECENT FINDINGS

To measure bleeding events consistently, an updated standardized definition has been developed by the Bleeding Academic Research Consortium (BARC) representatives. Additionally, the antithrombin agent bivalirudin has emerged as a frontrunner in the invasive management of acute coronary syndromes because of fewer bleeding complications, lower long-term mortality, and similar efficacy compared with heparin plus a glycoprotein IIb/IIIa inhibitor. The mortality benefit with bivalirudin is most likely correlated with reductions in major bleeding, including in-hospital, access-site, and nonaccess site bleeding, and despite the use of preprocedural unfractionated heparin.

SUMMARY

The BARC definition is an improved version of prior bleeding classifications, and will likely play a significant role in comparing different anticoagulation strategies in future clinical trials and registry analyses. Bivalirudin has been shown to reduce bleeding events in a multitude of diverse clinical settings and bleeding definitions, and has become the preferred antithrombotic agent in the setting of acute coronary syndromes.