Frequency and impact of bleeding in elective coronary stent clinical trials--utility of three commonly used definitions

Procedure-related bleeding in elective percutaneous coronary interventions

BACKGROUND

Prognostic impact of procedure-related bleeding in patients with stable coronary artery disease (CAD) undergoing elective percutaneous coronary intervention (PCI) remains incompletely investigated. The aim of this study was to investigate the association between peri-PCI bleeding and 1-year outcome of patients with stable CAD.

MATERIALS AND METHODS

The study included 9035 patients with stable CAD who underwent elective PCI. Bleeding within 30 days of PCI was defined using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality.

RESULTS

Bleeding occurred in 844 patients (9.3%). Actionable bleeding (BARC class ≥ 2) occurred in 442 patients (4.9%). There were 210 deaths (2.3%) at 1 year following PCI: 41 deaths among patients with bleeding and 169 deaths among patients without bleeding [Kaplan-Meier estimates of mortality, 4.9% and 2.1%; odds ratio = 2.41, 95% confidence interval (CI) 1.73-3.36, P < 0.001]. The association between bleeding and mortality remained significant after adjustment for baseline risk variables (adjusted hazard ratio = 1.87, 95% CI 1.27-2.76, P = 0.002). Bleeding increased the discriminatory power of the model regarding prediction of 1-year mortality (absolute and relative integrated discrimination improvement, 0.006% and 16.3%, respectively, P = 0.001).

CONCLUSIONS

In patients with stable CAD undergoing elective PCI, the occurrence of bleeding within 30 days of the procedure was associated with increased risk of death at 1 year after PCI. These findings suggest that procedure-related bleeding may contribute to less than optimal results of PCI in terms of mortality reduction in patients with stable CAD.

Shared decision making in patients with stable coronary artery disease: PCI choice

BACKGROUND

Percutaneous coronary intervention (PCI) and optimal medical therapy (OMT) are comparable, alternative therapies for many patients with stable angina; however, patients may have misconceptions regarding the impact of PCI on risk of death and myocardial infarction (MI) in stable coronary artery disease (CAD).

METHODS AND RESULTS

We designed and developed a patient-centered decision aid (PCI Choice) to promote shared decision making for patients with stable CAD. The estimated benefits and risks of PCI+OMT as compared to OMT were displayed in a decision aid using pictographs with natural frequencies and text. We engaged patients, clinicians, health service researchers, and designers with over 20 successive iterations of the decision aid, which were field tested during real-world clinical encounters involving clinicians and patients. The decision aid is intended to facilitate knowledge transfer, deliberation based on patient values and preferences, and shared decision making.

CONCLUSIONS

We describe the methods and outcomes of the design and development of a decision aid (PCI Choice) to promote shared decision making between clinicians and patients regarding the choice of PCI+OMT vs. OMT for treatment of stable CAD. We will evaluate the impact of PCI Choice on patient knowledge, decisional conflict, participation in decision-making, and treatment choice in an upcoming randomized trial.