Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions

Comparison of bivalirudin monotherapy versus unfractionated heparin plus tirofiban in patients with diabetes mellitus undergoing elective percutaneous coronary intervention

Bivalirudin demonstrated similar efficacy but resulted in a lower rate of bleeding compared to unfractionated heparin (UFH) plus platelet glycoprotein IIb/IIIa inhibitors in patients undergoing percutaneous coronary intervention. It has not been clearly evaluated whether this can also be applied to patients with diabetes mellitus. A total of 335 consecutive patients with diabetes mellitus referred for elective percutaneous coronary intervention were randomized in the Novel Approaches for Preventing or Limiting EventS (NAPLES) trial to receive bivalirudin monotherapy or UFH plus routine tirofiban. The primary composite end point (30-day composite incidence of death, urgent repeat revascularization, myocardial infarction, and all bleeding) was lower in the bivalirudin group than in the UFH plus tirofiban group (18.0% vs 31.5%, odds ratio 0.47, 95% confidence interval 0.28 to 0.79, p = 0.004). No death, urgent revascularization, or Q-wave myocardial infarction occurred. The rate of non-Q-wave myocardial infarction was similar in the 2 groups (10.2% in the bivalirudin group vs 12.5% in the UFH plus tirofiban group, p = 0.606). In contrast, fewer patients in the bivalirudin group experienced bleeding (8.4% vs 20.8%, odds ratio 0.34, 95% confidence interval 0.18 to 0.67, p = 0.002). This difference was mainly ascribed to the lower rate of minor bleeding (7.8% in the bivalirudin group vs 18.5% in the UFH plus tirofiban group, odds ratio 0.37, 95% confidence interval 0.19 to 0.74, p = 0.005), although the rate of major bleeding in the 2 groups was comparable (0.6% vs 2.4%, respectively; p = 0.371). In conclusion, in patients with diabetes mellitus undergoing elective percutaneous coronary intervention, the strategy of bivalirudin monotherapy compared to UFH plus routine tirofiban is safe and feasible and associated with a significant reduction of in-hospital bleeding.

A randomized comparison of a novel bioabsorbable vascular closure device versus manual compression in the achievement of hemostasis after percutaneous femoral procedures: the ECLIPSE (Ensure's Vascular Closure Device Speeds Hemostasis Trial)

OBJECTIVES

This trial compared the performance of a novel bioabsorbable vascular closure device (VCD) versus manual compression (MC) for access site hemostasis in patients undergoing percutaneous trans-femoral coronary or peripheral procedures.

BACKGROUND

From a patient's perspective, access site management after percutaneous procedures remains challenging.

METHODS

Patients enrolled in this multicenter, nonblinded trial underwent 6-F diagnostic or interventional procedures were randomly assigned 2:1 to VCD versus MC. The primary efficacy end points were time to hemostasis (TTH) and time to ambulation (TTA), and the primary safety end points were periprocedural and 30-day incidence of arterial access-related complications.

RESULTS

The trial assigned 401 patients (mean age 62.7 +/- 10.9 years, 66.1% men) to VCD (n = 267) versus MC (n = 134) after 87 "roll-in" patients treated at 17 participating institutions. The baseline characteristics of the groups were similar. Procedural success was 91.8% in the VCD versus 91.0% in the MC group (p = NS). Mean TTH was 4.4 +/- 11.6 min in the VCD versus 20.1 +/- 22.5 min in the MC group (95% confidence interval: 19.0 to 12.3; p < 0.0001). Likewise, TTA was significantly shorter in the VCD (2.5 +/- 5.0 h) than in the MC (6.2 +/- 13.3 h) group (95% confidence interval: 5.5 to 1.9; p = 0.0028). No patient died or suffered a major access-site-related adverse event. Minor adverse events were few among all study groups.

CONCLUSIONS

After 6-F percutaneous invasive procedures, TTH and TTA were both significantly shorter in patients assigned to VCD than in patients managed with MC. The 30-day rates of access-site-related complications were remarkably low in all groups. (Safety and Effectiveness Study of the Ensure Medical Vascular Closure Device; NCT00345631).

Value of blood transfusion in patients with a blood hematocrit of 24% to 30% after percutaneous coronary intervention

Bleeding is a serious complication after percutaneous coronary intervention (PCI). Red blood cell transfusions are liberally administered for a hematocrit decrease to <30% after PCI. However, the utility of transfusion for these hematocrit levels and its effect on the clinical outcome remains unclear. We investigated how red blood cell transfusion affects the clinical outcomes in patients with a hematocrit nadir of 24% to 30% after PCI. From a cohort of 5,538 consecutive patients who underwent PCI from 2003 to 2007, 625 patients who presented with nadir hematocrit levels of 24% to 30% after PCI were detected. Death and myocardial infarction were compared between the transfused (n = 189) and nontransfused (n = 436) patients at 30 days and 1 year. The clinical characteristics were similar in both groups, except for the incidence of myocardial infarction and cardiogenic shock as the initial clinical presentations, which were more frequent in the transfused patients: 30.7% versus 14% and 25.4% versus 8.1%, respectively (p <0.001). The mean hematocrit decrease was greater in the transfused patients: 13.23% versus 2.99% (p <0.001). The angiographic characteristics were also similar, except for the number of diseased vessels, which was greater in the transfused patients (2.43 vs 2.16, p = 0.01). The occurrence of death and myocardial infarction was greater in the transfused patients at 30 days (14.8% vs 7.1%, p <0.001) and 1 year (28.6% vs 19.6%, p = 0.01). After adjustment for the different co-morbidities and the mean hematocrit decrease, transfusion was no longer associated with worse outcomes at 30 days (hazard ratio 1.5, p = 0.2) or at 1 year (hazard ratio 1.4, p = 0.1). In conclusion, our data do not support the routine use of transfusion in patients who present with a nadir hematocrit of 24% to 30% after PCI.

Safety of intra-aortic balloon pump using glycoprotein IIb/IIIa antagonists

BACKGROUND

Anticoagulation with heparin is recommended with intra-aortic balloon pump (IABP) to prevent thrombosis and embolization. However, anticoagulation increases the risk of bleeding, particularly in combination with glycoprotein (GP) IIb/IIIa antagonists.

HYPOTHESIS

We investigated the safety of using GP IIb/IIIa antagonists without heparin after IABP insertion in patients who underwent primary percutaneous coronary intervention (PCI).

METHODS

Consecutive patients with acute myocardial infarction (AMI), who underwent primary PCI and were treated with GP IIb/IIIa antagonists without concomitant heparin, and in whom IABP was inserted, were followed during hospitalization for thrombotic and hemorrhagic complications.

RESULTS

Ninety-seven patients were included in this analysis. Glycoprotein IIb/IIIa antagonist treatment duration was 12-24 h in 89% of patients, and IABP duration was up to 48 h in 97% of patients. Three patients (3.1%) developed vascular complications: 1 had a major limb ischemia (long IABP treatment), 1 had a minor limb ischemia, and 1 had a cerebrovascular event (after prolonged resuscitation). All patients were already on heparin at the time of the thrombotic events. The rates of major and minor bleeding complications were 9% and 15.5%, respectively.

CONCLUSIONS

The rate of thrombotic complications is relatively low in post-primary PCI patients with IABP treated with GP IIb/IIIa antagonists without concomitant heparin therapy. Such an approach may reduce the risk of hemorrhagic complications, with low risk of thrombotic complications.

Bleeding increases the risk of ischemic events in patients with peripheral arterial disease

BACKGROUND

Patients with peripheral arterial disease are at high risk of ischemic events and therefore are treated with antithrombotics. In patients with coronary artery disease or cerebrovascular disease, bleeding is related to the subsequent occurrence of ischemic events. Our objective was to assess whether this is also the case in patients with peripheral arterial disease.

METHODS AND RESULTS

All patients from the Dutch Bypass and Oral Anticoagulants or Aspirin (BOA) Study, a multicenter randomized trial comparing oral anticoagulants with aspirin after infrainguinal bypass surgery, were included. The primary outcome event was the composite of nonfatal myocardial infarction, nonfatal ischemic stroke, major amputation, and cardiovascular death. To identify major bleeding as an independent predictor for ischemic events, crude and adjusted hazard ratios with 95% confidence intervals were calculated with multivariable Cox regression models. From 1995 until 1998, 2650 patients were included with 101 nonfatal major bleedings. During a mean follow-up of 14 months, the primary outcome event occurred in 218 patients; 22 events were preceded by a major bleeding. The mean time between major bleeding and the primary outcome event was 4 months. Major bleeding was associated with a 3-fold increased risk of subsequent ischemic events (crude hazard ratio, 3.0; 95% confidence interval, 1.9 to 4.6; adjusted hazard ratio, 3.0; 95% confidence interval, 1.9 to 4.7).

CONCLUSIONS

In patients with peripheral arterial disease, as in patients with coronary artery disease or cerebrovascular disease, major bleeding was independently associated with major ischemic complications. Without compromising the benefits of antithrombotics, these findings call for caution relative to the risks of major bleeding.

Bivalirudin in patients undergoing primary angioplasty for acute myocardial infarction (HORIZONS-AMI): 1-year results of a randomised controlled trial

BACKGROUND

In the HORIZONS-AMI trial, patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) who were treated with the thrombin inhibitor bivalirudin had substantially lower 30-day rates of major haemorrhagic complications and net adverse clinical events than did patients assigned to heparin plus a glycoprotein IIb/IIIa inhibitor (GPI). Here, we assess whether these initial benefits were maintained at 1 year of follow-up.

METHODS

Patients aged 18 years or older were eligible for enrolment in this multicentre, open-label, randomised controlled trial if they had STEMI, presented within 12 h after the onset of symptoms, and were undergoing primary PCI. 3602 eligible patients were randomly assigned by interactive voice response system in a 1:1 ratio to receive bivalirudin (0.75 mg/kg intravenous bolus followed by 1.75 mg/kg per h infusion; n=1800) or heparin plus a GPI (control; 60 IU/kg intravenous bolus followed by boluses with target activated clotting time 200-250 s; n=1802). The two primary trial endpoints were major bleeding and net adverse clinical events (NACE; consisting of major bleeding or composite major adverse cardiovascular events [MACE; death, reinfarction, target vessel revascularisation for ischaemia, or stroke]). This prespecified analysis reports data for the 1-year follow-up. Analysis was by intention to treat. Patients with missing data were censored at the time of withdrawal from the study or at last follow-up. This trial is registered with ClinicalTrials.gov, number NCT00433966.

FINDINGS

1-year data were available for 1696 patients in the bivalirudin group and 1702 patients in the control group. Reasons for participant dropout were loss to follow-up and withdrawal of consent. The rate of NACE was lower in the bivalirudin group than in the control group (15.6%vs 18.3%, hazard ratio [HR] 0.83, 95% CI 0.71-0.97, p=0.022), as a result of a lower rate of major bleeding in the bivalirudin group (5.8%vs 9.2%, HR 0.61, 0.48-0.78, p<0.0001). The rate of MACE was similar between groups (11.9%vs 11.9%, HR 1.00, 0.82-1.21, p=0.98). The 1-year rates of cardiac mortality (2.1%vs 3.8%, HR 0.57, 0.38-0.84, p=0.005) and all-cause mortality (3.5%vs 4.8%, HR 0.71, 0.51-0.98, p=0.037) were lower in the bivalirudin group than in the control group.

INTERPRETATION

In patients with STEMI undergoing primary PCI, anticoagulation with bivalirudin reduced the rates of net adverse clinical events and major bleeding at 1 year compared with treatment with heparin plus a GPI. This finding has important clinical implications for the selection of optimum treatment strategies for patients with STEMI.

FUNDING

Cardiovascular Research Foundation, with unrestricted grant support from Boston Scientific Corporation and The Medicines Company.

Prognostic impact of blood transfusion after primary angioplasty for acute myocardial infarction: analysis from the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trial

OBJECTIVES

We sought to determine the relationship between red blood cell (RBC) transfusion and clinical outcomes in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI).

BACKGROUND

The implications of RBC transfusion in patients undergoing primary PCI for AMI have not been evaluated.

METHODS

Clinical outcomes of patients from the prospective, randomized CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) trial were analyzed by administration of in-hospital RBC transfusion not related to coronary artery bypass surgery.

RESULTS

Of 2,060 randomized patients, 82 (3.98%) received RBC transfusion during the index hospitalization, including 33 (1.60%) with moderate/severe bleeding and 49 (2.38%) without overt major bleeding. Transfusion was independently associated with baseline anemia (odds ratio [95% confidence interval]: 4.44 [2.60 to 7.58], p < 0.0001), older age (1.03 [1.01 to 1.06], p = 0.002), triple-vessel disease (2.54 [1.47 to 4.38], p = 0.0008), and female sex (1.04 [1.02 to 1.06], p = 0.0008). Patients transfused versus not transfused had significantly higher rates of 1-year mortality (23.9% vs. 3.4%), disabling stroke (2.5% vs. 0.5%), reinfarction (7.0% vs. 2.2%), and composite major adverse cardiac events (41.0% vs. 16.6%) (all p values < 0.01). After multivariable adjustment for potential confounders including transfusion propensity, RBC transfusion was independently associated with mortality at 30 days (hazards ratio: 4.71, p = 0.0005) and 1 year (hazards ratio: 3.16, p = 0.0005).

CONCLUSIONS

An RBC transfusion after primary PCI in AMI may be harmful, which is consistent with the findings from other studies after PCI in the noninfarct setting. Alternatively, RBC transfusion may be a marker of markedly increased risk. Randomized studies are warranted to determine the optimal threshold for RBC transfusion in patients with AMI undergoing mechanical reperfusion therapy.

Transcarpal cardiac catheterization

INTRODUCTION

Even though the performance of coronary diagnostic and therapeutic procedures through the distal forearm arteries has become a well-established practice, only a small minority of procedures employ transcarpal approach. The aim of this review is to describe the state of art in cardiac catheterization through distal forearm arteries, to point out the advantages and disadvantages of this approach, and to discuss the specific aspects in which it differs from the transfemoral approach.

METHODS

A Medline search up to January 2009 and the articles retrieved were selectively evaluated. Practical recommendations are given based on the authors' experience.

RESULTS

The following advantages of the transcarpal approach to the coronary arteries, as compared to the transfemoral approach, were evident in 23 prospective randomized studies and registries: a lower risk of complications at the site of access (0.05% and 0.3% versus 2.3% and 2.8%), lower mortality (2.8% versus 3.9%), greater patient comfort, lower cost (14% and 15% lower), and a shorter hospital stay (1.5 days and 3 days versus 1.8 days and 4.5 days). Its disadvantages include the potential need for conversion to a transfemoral procedure, higher radiation exposure of the physician, and an extended learning curve, so that procedure times are longer and rates of technical failure are higher until about 400 procedures have been performed.

CONCLUSIONS

The current data give a favorable view of this procedure as long as its specific requirements in terms of pretreatment, choice of materials, technique, post-procedural care, and expertise of the physician are taken into account.

Transradial intervention for minimizing bleeding complications in percutaneous coronary intervention

Femoral arterial access site complications are responsible for a substantial proportion of the bleeding complications that occur in patients undergoing percutaneous coronary intervention (PCI). Because bleeding is associated with an increase in morbidity and mortality, pharmacologic and nonpharmacologic strategies associated with lower bleeding risk may improve outcomes. From this perspective, radial artery access, which is associated with a similar rate of success as femoral artery access with lower rates of bleeding, might become the "gold standard" for PCI. Although transradial technique requires a specific skill set and significant learning curve, success rates comparable to those of the femoral approach may be achieved. The benefits of radial access may be further enhanced by using antithrombotic strategies that maintain efficacy but limit bleeding risk. Indeed, a substantial proportion of bleeding complications unrelated to the access site occur, a finding that supports the use of safer antithrombotic regimens to optimize patient outcomes.

Selecting the optimal antithrombotic regimen for patients with acute coronary syndromes undergoing percutaneous coronary intervention

The wide variety of anticoagulant and antiplatelet agents available for clinical use has made choosing the optimal antithrombotic regimen for patients with acute coronary syndromes undergoing percutaneous coronary intervention a complex task. While there is no single best regimen, from a risk-benefit ratio standpoint, particular regimens may be considered optimal for different patients. We review the mechanisms of action for the commonly prescribed antithrombotic medications, summarize pertinent data from randomized trials on their use in acute coronary syndromes, and provide an algorithm (incorporating data from these trials as well as risk assessment instruments) that will help guide the decision-making process.

Feasibility and safety of prehospital administration of bivalirudin in patients with ST-elevation myocardial infarction

The selective thrombin inhibitor bivalirudin with a provisional glycoprotein IIb/IIIa inhibitor (GPI) has been shown to be comparable to heparin plus GPI in the rates of ischemic events but to significantly reduce the risk of bleeding complications in patients with acute coronary syndromes. The aim of this preliminary study was to describe the feasibility and safety of a switch from prehospital administration of unfractionated heparin to bivalirudin in ST-elevation acute myocardial infarction (STEMI) patients referred for primary percutaneous coronary intervention. Patients with STEMI treated with a 1-mg/kg bivalirudin bolus in the ambulance followed by infusion during angiography/primary percutaneous coronary intervention were compared with a STEMI control group (from the preceding year) treated with 10,000 U unfractionated heparin in the ambulance followed by in-hospital treatment with a GPI. A total of 102 patients (59%) receiving bivalirudin and 72 receiving heparin were followed during hospitalization. The baseline characteristics and prehospital treatment times were comparable between the 2 groups. The thrombolysis in myocardial infarction flow before and after primary percutaneous coronary intervention was similar. Stents were used significantly more often in the heparin-treated patients (90% versus 76%; p = 0.04), with bailout GPI for those receiving bivalirudin occurring in 30% compared with 83% of those receiving heparin (p <0.001). Significant bleeding complications were seen in <10% of all patients undergoing angiography with no difference between groups. Bivalirudin was easy to administer in the prehospital setting and did not affect the prehospital run times. In conclusion, the results suggest that prehospital bivalirudin administration is as safe and effective as heparin in the treatment of patients with STEMI. Prehospital administration seemed to reduce the need for GPI.

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

Advances in percutaneous coronary intervention (PCI) during the past decade have led to more widespread use of these procedures in older and sicker patients. Refinement of periprocedural antithrombotic therapy has played a particularly important role in reducing ischemic complications to very low levels in routine practice. Although the use of more powerful antiplatelet agents has been associated with increased risk of bleeding (especially among the elderly and patients with serious comorbidities), such complications have traditionally been viewed as benign in nature. Recent studies, however, have identified major bleeding after PCI as an important predictor of increased mortality. Whether this relationship between bleeding and risk of death is cause-and-effect, or merely an association based on shared risk factors, remains unclear. In this review, we examine the basis for a possible causal link between post-PCI bleeding and subsequent mortality. Possible mechanisms underpinning such a link are discussed, including a potential adverse role for blood transfusion in this setting. A framework for further clinical evaluation of this issue is presented.

Bleeding in Patients Undergoing Percutaneous Coronary Intervention

Background— Bleeding in patients undergoing percutaneous coronary intervention (PCI) is associated with increased morbidity, mortality, length of hospitalization, and cost. We identified baseline clinical characteristics associated with bleeding complications after PCI and developed a simplified, clinically useful algorithm to predict patient risk.

Methods and Results— Data were analyzed from 302 152 PCI procedures performed at 440 US centers participating in the National Cardiovascular Data Registry. As defined by the National Cardiovascular Data Registry, bleeding required transfusion, prolonged hospital stay, and/or a drop in hemoglobin >3.0 g/dL from any location, including percutaneous entry site, retroperitoneal, gastrointestinal, genitourinary, and other/unknown location. Bleeding complications occurred in 2.4% of patients. From the best-fitting model consisting of 15 clinical elements associated with post-PCI bleeding in a random 80% training cohort, we developed a parsimonious risk algorithm. Predictors of bleeding included age, gender, previous heart failure, glomerular filtration rate, peripheral vascular disease, no previous PCI, New York Heart Association/Canadian Cardiovascular Society Functional Classification class IV heart failure, ST-elevation myocardial infarction, non–ST-elevation myocardial infarction, and cardiogenic shock. The parsimonious model was validated in the remaining 20% of the population (c-statistic, 0.72) and in clinically relevant subgroups of patients. This simplified model was used to derive a clinical risk algorithm, with larger numbers corresponding with greater risk. In 3 categories, bleeding rates were greater in patients with higher estimates (≤7, 0.7%; 8 to 17, 1.8%; ≥18, 5.1%).

Conclusions— This report identifies baseline clinical factors associated with bleeding and proposes a clinically useful algorithm to estimate bleeding risk. This model is potentially actionable in altering therapeutic decision making and improving outcomes in patients undergoing PCI.

Major femoral bleeding complications after percutaneous coronary intervention: incidence, predictors, and impact on long-term survival among 17,901 patients treated at the Mayo Clinic from 1994 to 2005

OBJECTIVES

The purpose of this study was to evaluate secular trends and factors associated with major femoral bleeding after percutaneous coronary intervention (PCI) in routine clinical practice during the past decade and to assess the impact of these complications on outcomes including mortality.

BACKGROUND

Significant changes in patient demographic data, adjunctive pharmacotherapy, and access site management have occurred during the coronary stent era. Trends in major vascular complications after PCI during this time have not been well characterized.

METHODS

Consecutive patients who underwent transfemoral PCI from 1994 to 2005 at the Mayo Clinic (n = 17,901) were studied. Patients were divided into 3 groups: Group 1 (1994 to 1995, n = 2,441); Group 2 (1996 to 1999, n = 6,207); and Group 3 (2000 to 2005, n = 9,253).

RESULTS

The incidence of major femoral bleeding complications decreased (from 8.4% to 5.3% to 3.5%; p < 0.001). Reductions in sheath size, intensity and duration of anticoagulation with heparin, and procedure time were observed (p < 0.001), and multivariate analysis confirmed each as an independent predictor of complications (p < 0.001). Adverse outcomes of major femoral bleeding included prolonged hospital stay (mean 4.5 vs. 2.7 days; p < 0.0001) and increased requirement for blood transfusion (39% vs. 4.7%; p < 0.0001). Major femoral bleeding and blood transfusion were both associated with decreased long-term survival, driven by a significant increase in 30-day mortality (p < 0.001 for both).

CONCLUSIONS

We noted a marked decline in the incidence of major femoral bleeding after PCI over the past decade. Mortality associated with these bleeding complications and with blood transfusion remains a significant issue.

Balancing myocardial ischemic and bleeding risks in patients with non-ST-segment elevation myocardial infarction

Achieving an appropriate balance of anti-ischemic efficacy versus bleeding risk with antiplatelet and anticoagulant agents demands an accurate estimation of risks. Although traditional risk stratification is available to decrease complications, and various methods of stratifying these risks have been proposed and validated, the stratification of bleeding risk is in its infancy. However, no model currently available permits the simultaneous estimation of these risks. Ischemic risk may be determined using 1 of several validated models, followed by the estimation of bleeding risk according to known risk factors. After selecting appropriate pharmacotherapy on the basis of the stratification of these risks, attention must be paid to proper dosing according to individual risk factors and patient, clinical, and technical variables. The aim of this study was to examine risk stratification models for these parameters to determine clinical characteristics common to ischemia and bleeding that can be used to minimize risks. A "bleeding risk subscale" is proposed, with factors extrapolated from current ischemic risk models, to integrate ischemic mortality and bleeding risk in patients with non-ST-segment elevation acute coronary syndromes. In conclusion, a validated tool to simultaneously evaluate ischemic and bleeding risk will help determine the most well-balanced pharmacotherapy for patients with non-ST-segment elevation acute coronary syndromes.

Major bleeding complicating contemporary primary percutaneous coronary interventions-incidence, predictors, and prognostic implications

BACKGROUND

Major bleeding is one of the most frequent procedural-related complications of primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infraction (STEMI). We investigated the incidence, predictors, and prognostic impact of peri-procedural bleeding in a cohort of unselected patients undergoing contemporary primary PCI.

METHODS

A total of 831 consecutive patients who underwent primary PCI between 1/2001 and 6/2005 were studied. Major bleeding was defined as hemorrhagic stroke, hemoglobin (Hb) drop of >5 g%, or 3-5 g% with a need for blood transfusion. Clinical outcomes were evaluated at 30 days and 6 months.

RESULTS

Major bleeding occurred in 27 patients (3.5%). Those who experienced major bleeding were older (66+/-15 vs. 61+/-13, P=.02), more frequently female gender (48% vs. 27%, P=.0001), presented more often with cardiogenic shock (37% vs. 8%, P=.0001), and had higher CADILLAC score (7.8+/-4.5 vs. 5.1+/-4.0, P=.002) and activated clotting time (ACT) levels (284+/-63 vs. 248+/-57 s, P=.007). In multivariate analysis, significant predictors of major bleeding were female gender (OR 5.1, 95% CI 1.7-15.2, P=.004), ACT levels >250 s (OR 3.6, 95% CI 1.1-12.1, P=.04), and use of intra-aortic balloon pump (IABP) (OR 3.5, 95% CI 1.0-12.1, P=.047). Major bleeding was associated with increased 6-month mortality rates (37% vs. 10%, P=.0001), which remained significant after adjustment for baseline CADILLAC score (37% vs. 19.4%, P=.05).

CONCLUSIONS

Major bleeding complicating primary PCI is associated with increased 6-month mortality. Women and those who need IABP support are at particularly high risk. Tight monitoring of anticoagulation may reduce the risk of bleeding.

Impact of gender and antithrombin strategy on early and late clinical outcomes in patients with non-ST-elevation acute coronary syndromes (from the ACUITY trial)

Women with non-ST-elevation acute coronary syndrome are at increased risk for ischemic and bleeding complications compared with men. We examined the impact of gender and antithrombotic therapy for non-ST-elevation acute coronary syndrome on outcomes in patients in the ACUITY trial. Patients were randomized to heparin (unfractionated or enoxaparin) plus a glycoprotein IIb/IIIa inhibitor (GPI), bivalirudin plus a GPI, or bivalirudin alone. We compared major bleeding unconnected to coronary artery bypass grafting, composite ischemia (death, myocardial infarction, or revascularization), and net clinical outcome (composite ischemia or bleeding) in (1) men versus women overall and undergoing percutaneous coronary intervention (PCI) and (2) women overall and undergoing PCI by antithrombotic strategy. Of 13,819 patients enrolled, 4,157 were women (30.1%). Women had similar 30-day composite ischemia (7% vs 8%, p = 0.07) but greater 30-day rates of major bleeding (8% vs 3% p <0.0001) and net clinical outcomes (13% vs 10% p <0.0001) than men. One-year composite ischemia and mortality was similar. In women, bivalirudin compared with heparin + GPI resulted in less 30-day major bleeding (5% vs 10%, p <0.0001) but similar composite ischemia (7% vs 6%, p = 0.15). No differences were observed in rates of 1-year composite ischemia or mortality in women who received bivalirudin versus heparin + GPI. Results were similar in women undergoing PCI. In conclusion, women had similar 30-day mortality and composite ischemia but higher net clinical adverse events due to more bleeding complications than men; 1-year mortality was similar for men and women. In women, bivalirudin monotherapy compared with a GPI-based strategy resulted in significantly decreased bleeding but similar rates of 1-year composite ischemia and mortality.

Upper endoscopy in patients with acute myocardial infarction and upper gastrointestinal bleeding: results of a decision analysis

BACKGROUND

The management of patients with acute myocardial infarction (AMI) and upper gastrointestinal bleeding (UGIB) can present a challenge. The utility of upper endoscopy (esophagogastroduodenoscopy, EGD) and endoscopic therapy must be weighed against safety considerations.

AIM

To assess the utility and safety of EGD in patients with UGIB and AMI.

METHODS

Using decision analysis, patients with UGIB and AMI were assigned to one of two strategies: (1) EGD prior to cardiac catheterization (EGD strategy) and (2) cardiac catheterization without EGD (CATH strategy).

RESULTS

In patients with overt UGIB, the EGD strategy resulted in 97 deaths per 10,000 patients, compared with 600 deaths in the CATH strategy. The EGD strategy resulted in fewer non-fatal complications (1,271 vs. 6,000 per 10,000 patients). In patients with occult blood loss, the EGD strategy resulted in more deaths (59 vs. 16 per 10,000) and more non-fatal complications (888 vs. 160 per 10,000) than the CATH strategy.

CONCLUSIONS

Our analysis supports EGD prior to cardiac catheterization in patients with AMI and overt UGIB. This strategy results in fewer deaths and complications compared with a strategy of proceeding directly to catheterization. Our analysis does not support routine EGD prior to cardiac catheterization in patients with fecal occult blood.

Impact of anemia on physical function and survival among patients with coronary artery disease

BACKGROUND

Anemia is a purported risk factor for adverse outcomes, particularly among patients with cardiac disease. Although anemia at the time of discharge has been associated with poor functional status and survival, its impact over time is not clear.

HYPOTHESIS

Among patients with significant coronary artery disease (CAD), anemia (hemoglobin < 11 g/dL) is prevalent, and is associated with poor physical function (PF) and survival over time.

METHODS

Patients with significant CAD at the time of cardiac catheterization (n = 1, 821) were enrolled into a single-center, observational, and prospective study. All patients were followed for up to 1 y for clinical events and self-reported PF. Prevalence of anemia at discharge and its' associations with outcomes over time were examined.

RESULTS

Anemia at the time of discharge was very common (40.4%), and was associated with increased odds of death at 12 mo (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.12-2.15), yet other clinical factors accompanying anemia accounted for this association (adjusted OR 1.13, 95% CI 0.79-1.62). Discharge anemia was also associated with significantly lower self-reported PF at 6 and 12 mo (p < 0.05 for both); however, other clinical factors accompanying anemia also accounted for these associations.

CONCLUSIONS

Although discharge anemia is highly prevalent, its association with adverse outcomes is largely explained by baseline patient characteristics. Further research is needed to clarify the relationship between anemia and outcomes in this population and to identify subpopulations that do not recover independently and for whom available therapies may be beneficial.

Body mass index, periprocedural bleeding, and outcome following percutaneous coronary intervention (from the British Columbia Cardiac Registry)

The incidence of obesity is increasing throughout the industrialized world and is a major public health concern. Some studies have shown a paradoxical protective effect of moderate obesity on outcome after percutaneous coronary intervention (PCI). The association between bleeding, body mass, and outcome is not well established and formed the basis for the present study, which examined major bleeding rates and mortality after PCI in British Columbia during a 6-year period. We identified 38,346 consecutive patients from the British Columbia Cardiac Registry who underwent PCI from 1999 to 2005. Data were cross-referenced to determine outcomes at 30 days and 1 year. Information about bleeding after PCI was obtained by cross-referencing the British Columbia Cardiac Registry with the Central Transfusion Registry. Baseline patient characteristics were compared among body mass index (BMI) categories. A clear bimodal (U-shaped) relation was seen between BMI and mortality. BMI was a potent independent predictor of mortality, particularly evident in the underweight (BMI <18.5 kg/m(2); odds ratio [OR] 1.98, 95% confidence interval [CI] 1.6 to 2.5, p <0.0001) and morbidly obese (> or =40 kg/m(2); OR 1.61, 95% CI 1.28 to 2.08, p <0.0001) groups. Periprocedural transfusion was also associated with adverse outcome (OR 2.86, 95% CI 2.52 to 3.25, p <0.0001). Transfusion adopted the same bimodal distribution across the entire cohort. Emergent PCI and femoral access were procedural factors associated with outcome. In conclusion, major bleeding conferred an adverse long-term prognosis after PCI. Identifying demographic and procedural factors that increase risk will facilitate more accurate risk scoring of patients undergoing PCI and allow targeted bleeding-avoidance strategies. Body mass and female gender identified subgroups at much higher risk of bleeding after PCI, an observation that merits further study.

Expanding the recognition and assessment of bleeding events associated with antiplatelet therapy in primary care

Antiplatelet therapy is an evidence-based, guideline-recommended, worldwide standard of care for treatment of patients with atherothrombosis. However, clinical implementation of the guidelines is suboptimal, in part because of physician and patient nonadherence. The increased risk of bleeding associated with antiplatelet therapy is often the reason for nonadherence, and several programs have been created to increase adherence to guideline treatment recommendations. Despite the relative success of such initiatives, including Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines, Guidelines Applied in Practice, and the American Heart Association's Get With the Guidelines and a Science Advisory, a current estimate is that less than 50% of atherothrombotic patients are taking antiplatelet therapies as recommended by national guidelines. A PubMed and MEDLINE search of the literature (January 1, 1983-May 15, 2008) was performed to examine the bleeding risks associated with various antiplatelet therapies. Relevant clinical trials, observational registry data, and other studies relevant to treatment and guideline recommendations were selected from articles generated through specific search terms. This comprehensive review contributes to the understanding of the benefit-to-risk ratio of antiplatelet therapy for patients with atherothrombosis.

Expanding the recognition and assessment of bleeding events associated with antiplatelet therapy in primary care

Antiplatelet therapy is an evidence-based, guideline-recommended, worldwide standard of care for treatment of patients with atherothrombosis. However, clinical implementation of the guidelines is suboptimal, in part because of physician and patient nonadherence. The increased risk of bleeding associated with antiplatelet therapy is often the reason for nonadherence, and several programs have been created to increase adherence to guideline treatment recommendations. Despite the relative success of such initiatives, including Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines, Guidelines Applied in Practice, and the American Heart Association's Get With the Guidelines and a Science Advisory, a current estimate is that less than 50% of atherothrombotic patients are taking antiplatelet therapies as recommended by national guidelines. A PubMed and MEDLINE search of the literature (January 1, 1983-May 15, 2008) was performed to examine the bleeding risks associated with various antiplatelet therapies. Relevant clinical trials, observational registry data, and other studies relevant to treatment and guideline recommendations were selected from articles generated through specific search terms. This comprehensive review contributes to the understanding of the benefit-to-risk ratio of antiplatelet therapy for patients with atherothrombosis.

Incidence, predictors, and clinical impact of bleeding after transradial coronary stenting and maximal antiplatelet therapy

BACKGROUND

Bleeding has recently emerged as predictor of early and late mortality after percutaneous coronary intervention (PCI) using femoral approach. Transradial PCI is associated with a lower risk of access-site complications than femoral approach. We evaluated the predictors of bleeding and the impact of major bleeding on death and major adverse cardiac events (MACE) after transradial PCI and maximal antiplatelet therapy.

METHODS

In the EASY (EArly discharge after transradial Stenting of coronarY arteries) trial, 1,348 patients with acute coronary syndrome were enrolled and underwent transradial PCI. All patients received clopidogrel (90% > or =12 hours pre-PCI) and a bolus of abciximab before first balloon inflation. Univariate and multivariate analyses to identify predictors and prognostic impact of major bleeding on death and MACE (death, myocardial infarction, and target vessel revascularization) were performed.

RESULTS

From the study population, 19 (1.4%) patients presented major bleeding. Patients with bleeding were older, had lower creatinine clearance, more often had 3-vessel disease and > or =3 dilated sites, and had longer procedures. Independent predictors of bleeding were creatinine clearance <60 mL/min (odds ratio [OR] 3.26, 95% confidence interval [CI] 1.10-8.67, P = .022), procedure duration (OR 2.95, 95% CI 1.12-8.31, P = .032), and sheath size (OR 5.34, 95% CI 1.44-34.65, P = .029). In patients with major bleeding, the incidence of MACE was higher at 30 days (37% vs 3%), 6 months (42% vs 8%), and 12 months (53% vs 12%; P < .0001 for all comparisons). By multivariate analysis, major bleeding was an independent predictive factor of 1-year mortality and MACE.

CONCLUSION

After transradial PCI and maximal antiplatelet therapy, the incidence of major bleeding remains low. Major bleeding is an independent predictive factor of adverse acute and 1-year outcomes, regardless of the access site.

Major bleeding: management and risk reduction in acute coronary syndromes

BACKGROUND

Guidelines for the management of high-risk non ST-segment elevation acute coronary syndrome (NSTE ACS) recommend antithrombotic and antiplatelet therapy combined with an early invasive strategy. While this strategy reduces ischemic complications, it places patients at risk for bleeding complications.

OBJECTIVE

We sought to provide a narrative review of the risk factors for bleeding, risks associated with bleeding and strategies to prevent bleeding complications.

METHODS

A comprehensive literature review was performed to identify relevant evidence.

RESULTS/CONCLUSIONS

Bleeding complications in NSTE ACS are associated with adverse events and higher mortality. Prevention of bleeding complications can be achieved through judicious dosing of medications, the use of antithrombotic agents associated with a lower bleeding risk and use of the radial artery approach in patients requiring coronary intervention. Future work should focus on delineating the mechanisms underlying the bleeding-mortality relationship and developing a better understanding of the tradeoff between efficacy and safety.

Transfusion associated microchimerism: a heretofore little-recognized complication following transfusion

Potent antiplatelet and antithrombotic agents have significantly reduced mortality in the setting of acute coronary syndromes and percutaneous coronary intervention. However these agents are associated with increased bleeding which is in turn associated with adverse clinical outcomes. In many centers, transfusion is often used to correct for blood loss. Blood transfusion in the setting of acute coronary syndrome has been associated with adverse clinical outcomes including increased mortality. Transfusion associated microchimerism (TA-MC) is a newly recognized complication of blood transfusion. There is engraftment of the donor's hematopoietic stem cells in patients who then develop microchimerism. This article discusses the association of bleeding/blood transfusion with adverse outcomes and the potential role of TA-MC in clinical outcomes.