Balancing the benefits and risks of antiplatelet agents in patients with non-ST-segment elevated acute coronary syndromes and undergoing percutaneous coronary intervention

Temporal Trends, Predictors, and Outcomes of In-Hospital Gastrointestinal Bleeding Associated With Percutaneous Coronary Intervention

Since the introduction of new antiplatelet and anticoagulant agents in the last decade, large-scale data studying gastrointestinal bleeding (GIB) in patients undergoing percutaneous coronary intervention (PCI) are lacking. Using the Nationwide Inpatient Sample, we identified all hospitalizations from 2006 to 2012 that required PCI. Temporal trends in the incidence and multivariate predictors of GIB associated with PCI were analyzed. A total of 4,376,950 patients underwent PCI in the United States during the study period. The incidence of GIB was 1.1%. Mortality rate in the GIB group was significantly higher (9.71% vs 1.1%, p <0.0001). Although the incidence of GIB remained stable during the study period (0.97% in 2006 to 1.19% in 2012), in-hospital mortality rate increased significantly from 7.9% in 2006 to 10.78% in 2012, with a peak of 12% in 2010. The GIB group had a longer median length of stay (5.80 vs 1.57 days) and an increased median cost of hospitalization ($26,564 vs $16,879). The predictors of GIB included cardiovascular co-morbidities such as acute myocardial infarction, cardiogenic shock, atrial fibrillation, congestive heart failure, valvular heart diseases, and a history of transient ischemic attack/stroke. Gastrointestinal co-morbidities including diverticulosis, esophageal cancer, stomach cancer, small intestine cancer, large intestine cancer, rectosigmoid cancer, gastrointestinal ulcer, and liver disease were predictors of GIB. Interestingly, a lower risk of GIB was associated with obese patients and patients with private insurance. A higher risk of GIB was noted in urgent versus elective admissions and weekend versus weekday admissions. In conclusion, the incidence of GIB in patients who underwent PCI remained stable from 2006 to 2012; however, the in-hospital mortality increased significantly. Identifying patients at higher risk for GIB is critically important to develop preventive strategies to reduce morbidity and mortality.

HAS-BLED score predicts risk of in-hospital major bleeding in patients with acute non-ST segment elevation myocardial infarction

BACKGROUND

The role of the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs or alcohol use (HAS-BLED) score in the prediction of in-hospital bleeding in non-ST segment elevation myocardial infarction (NSTEMI) patients receiving dual anti-platelet therapy plus heparin was unknown. In this study, we compared the HAS-BLED score with the Can Rapid Risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) and Acute Catheterization and Urgent Intervention Triage strategY and the Harmonizing Outcomes with RevascularIZatiON and Stents in acute myocardial infarction (ACUITY-HORIZONS) bleeding risk scores for in-hospital major bleeding risk stratification in NSTEMI patients.

METHODS

A real world population of 617 NSTEMI patients receiving dual anti-platelet plus heparin as initial therapy were enrolled. CRUSADE, ACUITY-HORIZONS and HAS-BLED risk scores were calculated for each patient.

RESULTS

This cohort had a 6.5% incidence of in-hospital major bleeding. For the prediction of in-hospital major bleeding, the discriminations between CRUSADE, ACUITY-HORIZONS and HAS-BLED were good (C-statistic 0.81, 0.82 and 0.80, respectively). There was no significant difference between these three risk scores (HAS-BLED vs. CRUSADE: z=-0.08, p=0.27; HAS-BLED vs. ACUITY-HORIZONS: z=-0.06, p=0.26; CRUSADE vs. ACUITY-HORIZONS: z=-0.15, p=0.28).

CONCLUSION

The CRUSADE, ACUITY-HORIZONS and HAS-BLED scores were useful tools for risk stratification of in-hospital major bleeding in NSTEMI patients. The HAS-BLED score had a simpler calculation and a similar accuracy for risk assessment as the other two scores evaluated.

Acute gastrointestinal bleeding after percutaneous coronary intervention

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