Major bleeding complicating contemporary primary percutaneous coronary interventions-incidence, predictors, and prognostic implications. Cardiovasc Revasc Med. 2009;10:88-93. [PMID: 19327670 DOI: 10.1016/j.carrev.2008.08.001]

The prevalence of bleeding after percutaneous coronary interventions: A systematic review and meta-analysis

BACKGROUND

Bleeding is a common complication associated with percutaneous coronary intervention (PCI). The aim of this study was to determine the prevalence of bleeding after PCI through a systematic review and meta-analysis.

METHODS

The systematic review and meta-analysis covered the period from 1989 to 2023. Multiple databases, including Embase, PubMed, Scopus, Web of Sciences (WoS), MagIran, Scientific Information Database (SID), and Google Scholar, were searched using validated keywords with MeSH and Emtree. The I2 index was used to check for heterogeneity among studies.

RESULTS

The review of 8 studies, with a sample size of 397,298 participants, showed high heterogeneity (I2: 97.8 %). Therefore, the random effects method was used to analyze the results. The prevalence of bleeding after intervention in percutaneous coronary arteries was reported to be 4.4 % (95%CI: 2-9.1).

CONCLUSION

This meta-analysis showed a significant prevalence of bleeding after PCI, highlighting the need for health policymakers to pay more attention to the complications associated with PCI. Interventional cardiologists should consider the effective factors in these bleeding and how to treat and control them due to the importance of this complication.

Feasibility and safety values of activated clotting time-guided systemic heparinization in coil embolization for unruptured intracranial aneurysms

OBJECTIVE

This study aimed to evaluate the feasibility and safety values of activated clotting time (ACT)-guided systemic heparinization in reducing periprocedural thrombosis and bleeding complications during coil embolization of unruptured intracranial aneurysms.

METHODS

A total of 228 procedures performed on 213 patients between 2016 and 2021 were included in the retrospective analysis. The target ACT was set at 250 s. Logistic regression was performed to assess predictors for the occurrence of thrombosis and bleeding. Receiver operating characteristic (ROC) analyses were employed to determine the optimal cut-off values for ACT, heparinization, and procedure time.

RESULTS

Most (85.1%) of procedures were stent-assisted embolization. The mean baseline ACT was 128.8 ± 45.7 s. The mean ACT at 20 min after the initial intravenous heparin loading of 78.2 ± 18.8 IU/kg was 185 ± 46.4 s. The mean peak ACT was 255.6 ± 63.8 s with 51.3% (117 cases) achieving the target ACT level. Peak ACT was associated with symptomatic thrombosis (OR per second, 1.008; 95% CI, 1.000-1.016; P = 0.035) (cut-off value, 275 s; area under ROC (AUROC), 0.7624). Total administered heparin dose per body weight was negatively associated with symptomatic thrombosis (OR per IU/kg, 0.972; 95% CI, 0.949-0995; P = 0.018) (cut-off value, 294 IU/kg; AUROC, 0.7426) but positively associated with significant bleeding (OR, 1.008 per IU/kg; 95% CI, 1.005-1.012; P <0 .001) (cut-off value, 242 IU/kg; AUROC, 0.7391). Procedure time was significantly associated with symptomatic thrombosis (OR per minute, 1.05; 95% CI, 1.017-1.084; P value = 0.002) (cut-off value, 158 min; area under ROC, 0.8338).

CONCLUSION

This study demonstrated that ACT-guided systemic heparinization was feasible to achieve the target ACT value and proposes probable safety thresholds to prevent periprocedural complications through reducing procedure time during coil embolization of unruptured intracranial aneurysms in the stent era.

Gender Differences in Clinical Outcomes After Percutaneous Coronary Intervention-Analysis of 15,106 Patients from the Cardiac Registry of Pakistan Database

There is a scarcity of data on gender differences in outcomes during and after percutaneous coronary intervention (PCI) in the South Asian population. We assessed the gender differences in in-hospital mortality and complications in patients who underwent PCI. We conducted a cross-sectional study of 15,106 patients from the CROP (Cardiac Registry of Pakistan) CathPCI database. Logistic regression was used to determine factors associated with in-hospital mortality (primary outcome), access site hematoma, and bleeding complications. Approximately 19.6% were women. Women were older (mean age = 57.3 vs 54.4 years) and had a higher prevalence of diabetes (49.3% vs 32.6%), hypertension (72.8% vs 56.4%), peripheral arterial disease (1.5% vs 1%), and cerebrovascular accident (1.2% vs 0.8%) than men (p <0.05).Unadjusted in-hospital mortality was higher in women than in men (odds ratio [OR]: 1.6, 95% confidence interval [CI] 1.1 to 2.2); however, after adjusting for age, hypertension, diabetes, history of cerebrovascular accident, and ST-elevation myocardial infarction at presentation in the multiple logistic regression model, in-hospital mortality was comparable between men and women (adjusted OR [AOR] 1.2, 95% CI 0.8 to 1.7). The results remained consistent after propensity score matching of 5,904 patients (2,952 in each group, OR 1.3, 95% CI 0.9 to 2.0 for in-hospital mortality). Bleeding complications (1.2% vs 0.4%, AOR 2.6, 95% CI 1.4 to 4.5) and access site hematoma (2% vs 0.6%, AOR 2.8, 95% CI 1.8 to 4.5) were higher in women than in men. In conclusion, the incidence of in-hospital mortality was higher for women versus men, but adjusted risks were similar, likely driven by a greater co-morbidity burden among women.

Racial and Gender Disparity in Aortoiliac Disease Open Revascularization Procedures

BACKGROUND

The impact of race and gender on surgical outcomes has been studied in infrainguinal revascularization for peripheral arterial disease. The aim of this study is to explore how race and gender affect the outcomes of suprainguinal bypass (SIB) for aortoiliac occlusive disease.

MATERIALS AND METHODS

Patients who underwent SIB were identified from the procedure-targeted National Surgical Quality Improvement Program data set (2011-2016). Patients were stratified into four groups: nonblack males, black males (BM), nonblack females, and black females (BF). Primary outcomes were 30-d major adverse cardiac events, a composite of myocardial infarction, stroke, or death; postoperative bleeding requiring transfusion or intervention; major amputation and prolonged length of stay (>10 d). Predictors of outcomes were determined by multivariable logistic regression analysis.

RESULTS

About 5044 patients were identified. BM were younger, more likely to be smokers, less likely to be on antiplatelet drug or statin, and to receive elective SIB (all P ≤ 0.01). BFs were more likely to be diabetic and functionally dependent (all P ≤ 0.02). Major adverse cardiac events were not significantly different among all groups. BM had a threefold higher risk of amputation (adjusted odds ratio [OR] [95% confidence interval (95% CI)], 3.10 [1.50-6.43]; P < 0.002). Female gender was associated with bleeding in both races, that association was more drastic in BF (OR [95% CI], 2.43 [1.63-3.60]; P < 0.0001), whereas nonblack females (OR [95% CI], 1.46 [1.19-1.80]; P < 0.0001). BF had higher odds of prolonged length of stay (OR [95% CI]: 1.62 [1.08-2.42]; P < 0.019).

CONCLUSIONS

In this large retrospective study, we demonstrated the racial and gender disparity in SIB outcomes. BM had more than threefold increase in amputation risk as compared with nonblack males. Severe bleeding risk was more than doubled in BF. Race and gender consideration is warranted in risk assessment when patients are selected for aortoiliac disease revascularization, which in turn necessitate preoperative risk modification and optimization in addition to enhancing their access to primary preventive care measures.

Prognostic impact of body mass index on in-hospital bleeding complications after ST-segment elevation myocardial infarction

BACKGROUND

ST-elevation myocardial infarction (STEMI) remains a major cause of mortality despite early revascularization and optimal medical therapy. Tailoring individual management by considering patients’ specificities may help in improving post-STEMI survival.

AIM

To evaluate whether in-hospital bleeding complications may be involved in post STEMI prognosis among overweight patients.

METHODS

We prospectively included 2070 patients with a STEMI between January 2005 and December 2012 in the French observational cohort, “Registre d’Infarctus Maine-Anjou”. Bleeding Academic Research Consortium (BARC) in-hospital bleeding complications were recorded.

RESULTS

Of 705 patients (35.3%) were presented as being of normal weight, defined as a body mass index (BMI) < 25 kg/m², 877 (43.9%) had a BMI between 25 and 30 kg/m² and 416 (20.8%) had a BMI ≥ 30 kg/m². One-year cardiovascular mortality was lower for BMI ≥ 25 kg/m² (5.3% and 7.1%) patients than for normal weight patients (10.8%) (P = 0.001). We found an interaction between the effect of BARC 3 on mortality and BMI groups. While a BARC 3 was related to a higher 1-year mortality in general (HR: 2.58, 95%CI: 1.44-4.64, P ≤ 0.001), prognosis was even worse in normal weight patients (HR: 2.97, 95%CI: 1.61-5.5, P < 0.001) than for patients with a BMI ≥ 25 kg/m² (HR: 1.94, 95%CI: 1.02-3.69, P = 0.041).

CONCLUSION

Normal weight patients presented higher rates of in-hospital bleeding complications and lower survival after a STEMI. Excess mortality might be due to greater vulnerability to bleeding amongst normal weight patients.

Feasibility of coronary fractional flow reserve with dual anti-platelet therapy in low risk coronary lesions without systemic anticoagulation-results of the SMART-FFR study

BACKGROUND

Fractional flow reserve (FFR) is used to assess the functional significance of coronary artery stenoses. The optimal anti-thrombotic regimen for FFR has not been studied.

PURPOSE

The goal of this study was to determine whether FFR could be safely performed in Type A coronary lesions, using only upstream dual anti-platelet therapy (DAT) with aspirin and clopidogrel, compared with DAT plus anticoagulation in low risk coronary lesions.

METHODS/MATERIALS

Two hundred patients undergoing FFR for Type A intermediate coronary lesions were blindly randomized into two groups of 100 patients each. Group 1: Upstream DAT, without intra-procedural anti-coagulation and Group 2: Upstream DAT plus intra-procedural bivalirudin. The primary end-points were any coronary thrombotic complications during the index hospital stay, and a composite end-point of any major adverse cardiovascular events (MACE) at 30-days. Secondary end-points included post-procedure troponin levels and TIMI major and minor bleeding scores.

RESULTS

There were no thrombotic complications reported. At 30-days, two MACE occurred in Group 1, and three in Group 2 (p=0.83). No difference was seen in the post-procedure troponin levels (p=0.72), or TIMI bleeding scores study between groups (p=093).

CONCLUSIONS

This initial study evaluating a simplified anti-thrombotic regimen for FFR, suggests that FFR can be performed in low risk coronary lesions using DAT without the need for intra-procedural anticoagulation, with similar results as DAT plus anticoagulation with bivalirudin. Further research in this area is needed to determine the optimal and most cost-effective anti-thrombotic regimen for FFR calculation.

Clinical outcomes of patients with acute coronary syndrome and moderate or severe chronic anaemia undergoing coronary angiography or intervention

BACKGROUND

There are limited data on the impact of chronic moderate or severe anaemia on the clinical outcomes of patients with acute coronary syndrome undergoing coronary angiography or percutaneous coronary intervention.

METHODS

We retrospectively compared two groups of consecutive patients with acute coronary syndrome according to their haemoglobin level on admission. The research group ( n=89) had a haemoglobin level of 10.9 g/dl or less and a control group ( n=79) of age-matched patients had a haemoglobin level greater than 10.9 g/dl. We studied drug therapy before, during and after intervention, and performed 1-year follow-up of bleeding complications according to the Bleeding Academic Research Consortium criteria, all-cause mortality and re-infarction, as well as haemoglobin level on discharge, 6 and 12 months after admission.

RESULTS

Compared to controls, a haemoglobin level less than 10.9 g\dl on admission is associated with a higher rate of major bleeding: 26 patients (32%) versus none in the control group ( P<0.001); and the use of packed red blood cell (RBC) transfusion: nine patients (11.7%) versus none in the control group ( P=0.003) within the first 6 months post-catheterisation. However, the re-infarction rate and mortality were similar in the study and control groups: 9.2% versus 9.7% ( P=0.915) and 12.6% versus 8.9% ( P=0.434), accordingly.

CONCLUSIONS

Chronic moderate or severe anaemia in patients with acute coronary syndrome undergoing coronary angiography or percutaneous coronary intervention is associated with a substantially increased risk of bleeding in the first 6 months. However, rates of mortality and re-infarction were similar.

Does anemia affect the predictive ability of bleeding risk scores in patients with acute coronary syndromes?

INTRODUCTION AND OBJECTIVE

Anemia is a common comorbidity in patients with acute coronary syndromes (ACS), and is associated with higher risk for both bleeding and ischemic complications. We aimed to assess the predictive ability of bleeding risk scores (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines [CRUSADE], Mehran and Acute Coronary Treatment and Intervention Outcomes Network [ACTION]) in ACS patients with anemia.

METHODS

All consecutive ACS patients were prospectively included. The primary outcome was in-hospital major bleeding according to the CRUSADE, Mehran and ACTION definitions. Anemia was defined as hemoglobin <130 g/l in men and <120 g/l in women. The predictive ability of the bleeding risk scores was assessed by binary logistic regression, calculating receiver operating characteristic (ROC) curves and their corresponding area under the curve (AUC).

RESULTS

We included 2255 patients, mean age 62.4 years. Anemia was present in 550 patients (24.4%). Patients with anemia had a significantly higher prevalence of comorbidities. The three bleeding risk scores adequately predicted major bleeding in the whole cohort. No significant differences were observed regarding the predictive ability of each of the scores in patients with and without anemia (CRUSADE: AUC 0.73 without anemia vs. 0.74 with anemia, p=0.913; ACTION: AUC 0.68 without anemia vs. 0.73 with anemia, p=0.353; Mehran: AUC 0.69 without anemia vs. 0.61 with anemia, p=0.210). Only the Mehran score showed significantly lower predictive ability in patients with hemoglobin <11 g/dl (AUC 0.51, p=0.044).

CONCLUSIONS

Anemia was a common comorbidity in patients with ACS from our series. Currently available bleeding risk scores showed an adequate predictive ability in patients with mild anemia.

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

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

Transradial Primary Percutaneous Coronary Intervention

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

Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock

BACKGROUND

Intra-aortic balloon pump counterpulsation (IABP) is currently the most commonly used mechanical assist device for patients with cardiogenic shock due to acute myocardial infarction. Although there has been only limited evidence from randomised controlled trials, the previous guidelines of the American Heart Association/American College of Cardiology (AHA/ACC) and the European Society of Cardiology (ESC) strongly recommended the use of the IABP in patients with infarction-related cardiogenic shock on the basis of pathophysiological considerations, non-randomised trials and registry data. The recent guidelines downgraded the recommendation based on a meta-analysis which could only include non-randomised trials showing conflicting results. Up to now, there have been no guideline recommendations and no actual meta-analysis including the results of the large randomised multicentre IABP-SHOCK II Trial which showed no survival benefit with IABP support. This systematic review is an update of the review published in 2011.

OBJECTIVES

To evaluate, in terms of efficacy and safety, the effect of IABP versus non-IABP or other assist devices guideline compliant standard therapy on mortality and morbidity in patients with acute myocardial infarction complicated by cardiogenic shock.

SEARCH METHODS

Searches of CENTRAL, MEDLINE (Ovid) and EMBASE (Ovid), LILACS, IndMed and KoreaMed, registers of ongoing trials and proceedings of conferences were updated in October 2013. Reference lists were scanned and experts in the field contacted to obtain further information. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials on patients with acute myocardial infarction complicated by cardiogenic shock.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the published protocol. Individual patient data were provided for six trials and merged with aggregate data. Summary statistics for the primary endpoints were hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs).

MAIN RESULTS

Seven eligible studies were identified from a total of 2314 references. One new study with 600 patients was added to the original review. Four trials compared IABP to standard treatment and three to other percutaneous left assist devices (LVAD). Data from a total of 790 patients with acute myocardial infarction and cardiogenic shock were included in the updated meta-analysis: 406 patients were treated with IABP and 384 patients served as controls; 339 patients were treated without assisting devices and 45 patients with other LVAD. The HR for all-cause 30-day mortality of 0.95 (95% CI 0.76 to 1.19) provided no evidence for a survival benefit. Different non-fatal cardiovascular events were reported in five trials. During hospitalisation, 11 and 4 out of 364 patients from the intervention groups suffered from reinfarction or stroke, respectively. Altogether 5 out of 363 patients from the control group suffered from reinfarction or stroke. Reocclusion was treated with subsequent re-revascularization in 6 out of 352 patients from the intervention group and 13 out of 353 patients of the control group. The high incidence of complications such as moderate and severe bleeding or infection in the control groups has to be attributed to interventions with other LVAD. Possible reasons for bias were more frequent in small studies with high cross-over rates, early stopping and the inclusion of patients with IABP at randomisation.

AUTHORS' CONCLUSIONS

Available evidence suggests that IABP may have a beneficial effect on some haemodynamic parameters. However, this did not result in survival benefits so there is no convincing randomised data to support the use of IABP in infarct-related cardiogenic shock.

Access site complications after peripheral vascular interventions: incidence, predictors, and outcomes

BACKGROUND

Access site hematomas and pseudoaneurysms are the most frequent complications of peripheral vascular intervention (PVI); however, their incidence and risk factors remain unclear.

METHODS AND RESULTS

We retrospectively analyzed data from the multicenter Vascular Quality Initiative on 22 226 patients who underwent 27 048 PVI from August 2007 to May 2013. Primary end points included incidence and predictors of access site complications (ASCs), length of postprocedural hospitalization, discharge status, and 30-day and 1-year mortality. ASC complicated 936 procedures (3.5%). Of these, 74.4% were minor complications, 9.7% were moderate requiring transfusion, 5.4% were moderate requiring thrombin injection, and 10.5% were severe requiring surgery. Predictors of ASC were age >75 years, female sex, white race, no prior PVI, nonfemoral arterial access site, >6-Fr sheath size, thrombolytics, arterial dissection, fluoroscopy time >30 minutes, nonuse of vascular closure device, bedridden preoperative ambulatory status, and urgent indication. Mean hospitalization was longer after procedures complicated by ASC (1.2±1.6 versus 1.9±1.9 days; range, 0-7 days; P=0.002). Severity of ASC correlated with higher rates of discharge to rehabilitation/nursing facilities compared with home discharge. Patients with severe ASC had higher 30-day mortality (6.1% versus 1.4%; P<0.001), and those with moderate ASC requiring transfusion had elevated 1-year mortality (12.1% versus 5.7%; P<0.001).

CONCLUSIONS

Several factors independently predict ASC after PVI. Appropriate use of antithrombotic therapies and vascular closure device in patients at increased risk of ASC may improve post-PVI outcomes.

Arterial access site utilization in cardiogenic shock in the United Kingdom: is radial access feasible?

BACKGROUND

Cardiogenic shock (CS) remains the leading cause of mortality in patients hospitalized with acute myocardial infarction (AMI). The transradial access site (TRA) has become increasingly adopted as a default access site for percutaneous coronary intervention (PCI); however, even in experienced centers that favor the radial artery as the primary access site during PCI, patients presenting in CS are often treated via the transfemoral access site (TFA); and commentators have suggested that CS remains the final frontier that has given even experienced radial operators pause. We studied the use of TRA in patients presenting in CS in a nonselected high-risk cohort from the British Cardiovascular Intervention database over a 7-year period (2006-2012).

METHODS

Mortality (30-day) and major adverse cardiac and cerebrovascular events (a composite of in-hospital mortality, in-hospital myocardial reinfarction, target vessel revascularization, and cerebrovascular events) were studied based on TFA and TRA utilization in CS patients. The influence of access site selection was studied in 7,231 CS patients; TFA was used in 5,354 and TRA in 1,877 patients.

RESULTS

Transradial access site was independently associated with a lower 30-day mortality (hazard ratio [HR] 0.56, 95% CI 0.46-0.69, P = 0 < .001), in-hospital major adverse cardiac and cerebrovascular events (HR 0.64, 95% CI 0.53-0.76, P < .0001) and major bleeding (HR 0.37, 95% CI 0.18-0.73, P = .004).

CONCLUSIONS

Although the majority of PCI cases performed in patients with cardiogenic shock in the United Kingdom are performed through the TFA, the radial artery represents an alternative viable access site in this high-risk cohort of patients in experienced centers.

Age and sex differences in inhospital complication rates and mortality after percutaneous coronary intervention procedures: evidence from the NCDR(®)

BACKGROUND

Older women experience higher complication rates and mortality after percutaneous coronary intervention (PCI) than men, but there is limited evidence about sex-based differences in outcomes among younger patients. We compared rates of complications and inhospital mortality by sex for younger and older PCI patients.

METHODS

A total of 1,079,751 hospital admissions for PCI were identified in the CathPCI Registry(®) from 2005 to 2008. Complication rates (general, bleeding, bleeding with transfusion, and vascular) and inhospital mortality after PCI were compared by sex and age (<55 and ≥55 years). Analyses were adjusted for demographic and clinical factors and stratified by PCI type (elective, urgent, or emergency).

RESULTS

Overall, 6% of patients experienced complications, and 1% died inhospital. Unadjusted complication rates were higher for women compared with men in both age groups. In risk-adjusted analyses, younger women (odds ratio 1.24, 95% CI 1.16-1.33) and older women (1.27, 1.09-1.47) were more likely to experience any complication than similarly aged men. The increased risk persisted across complication categories and PCI type. Within age groups, risk-adjusted mortality was marginally higher for young women (1.19, 1.00-1.41), but not for older women (1.03, 0.97-1.10). In analyses stratified by PCI type, young women had twice the mortality risk after an elective procedure as young men (2.04, 1.15-3.61).

CONCLUSIONS

Women, regardless of age, experience more complications after PCI than men; young women are at increased mortality risk after an elective PCI. Identifying strategies to reduce adverse outcomes, particularly for women younger than 55 years, is important.

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.

Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures

Echocardiographic guidance has an important role in percutaneous cardiovascular procedures and vascular access. The advantages include real time imaging, portability, and availability, which make it an effective imaging modality. This article will review the role of echocardiographic guidance for diagnostic and therapeutic percutaneous procedures, specifically, transvenous and transarterial access, pericardiocentesis, endomyocardial biopsy, transcatheter pulmonary valve replacement, pulmonary valve repair, transcatheter aortic valve implantation, and percutaneous mitral valve repair. We will address the ways in which echocardiographic guidance provides these procedures with detailed information on anatomy, adjacent structures, and intraprocedural instrument position, thus resulting in improvement in procedural efficacy, safety and patient outcomes.

Clinical review: bleeding - a notable complication of treatment in patients with acute coronary syndromes: incidence, predictors, classification, impact on prognosis, and management

This article focuses on the incidence, predictors, classification, impact on prognosis, and management of bleeding associated with the treatment of acute coronary syndrome. The issue of bleeding complications is related to the continual improvement of ischemic heart disease treatment, which involves mainly (a) the widespread use of coronary angiography, (b) developments in percutaneous coronary interventions, and (c) the introduction of new antithrombotics. Bleeding has become an important health and economic problem and has an incidence of 2.0% to 17%. Bleeding significantly influences both the short- and long-term prognoses. If a group of patients at higher risk of bleeding complications can be identified according to known risk factors and a risk scoring system can be developed, we may focus more on preventive measures that should help us to reduce the incidence of bleeding.

The Role of the Transradial Approach for Complex Coronary Interventions in Patients with Acute Coronary Syndrome

Despite advances in antithrombotic and antiplatelet therapy, bleeding complications remain an important cause of morbidity and mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). A significant proportion of such bleedings are related to the access site, and adoption of transradial access (TRA) may reduce these complications. In patients with ST-segment elevation myocardial infarction (STEMI), TRA reduced cardiac mortality in comparison with the femoral approach (TFA). High-risk patients such as women, obese patients and elderly subjects who are at increased risk for vascular complications and bleeding, might particularly benefit from the TRA. However, specific radial expertise providing procedural time and a success rate comparable to those with the TFA are strongly recommended before using this technique in the emergency setting.

Comparison of costs between transradial and transfemoral percutaneous coronary intervention: a cohort analysis from the Premier research database

BACKGROUND

Transradial intervention (TRI) for percutaneous coronary intervention (PCI) is associated with shorter length of stay, fewer bleeding complications, and higher patient satisfaction. Less is known about the economic implications of TRI in contemporary practice.

METHODS

This is a retrospective inpatient cohort analysis using medical data from the Premier research database (Premier Inc, Charlotte, NC), which contains approximately one-fifth of all acute care hospitalizations in the US annually. The database was queried to identify patients undergoing PCI from 2004 to 2009. Patients with TRI were identified by center-level charge codes for radial-specific devices and matched one-to-many with patients undergoing transfemoral intervention (TFI). Adjusted total hospitalization costs were compared between patients undergoing TRI and TFI. Patients were additionally classified by periprocedural risk of bleeding as low (<1%), moderate (1%-3%), and high (>3%).

RESULTS

There were 609 TRI cases matched with 60,900 TFI cases. Total adjusted costs for TRI were $11,736 ± $6,748 vs $12,288 ± $23,418 for TFI, a difference of $553 favoring TRI (95% CI $45-$1,060, P = .033). Day-of-procedure costs were similar, at $17 higher for TRI compared with TFI (95% CI -$318 to $353, P = .37); however, costs from the following day until discharge were significantly lower for TRI (-$571, 95 % CI -$912 to $229, P = .001). Postprocedure costs were lower for patients with TRI vs patients with TFI at moderate (-$478, 95% CI -$887 to $69, P = .022) and high (-$917, 95% CI -$1,814 to $19, P = .045) risk of bleeding.

CONCLUSIONS

In a nationwide administrative hospital database, transradial compared with transfemoral PCI access was associated with lower average direct hospital costs and shorter length of hospital stay. Postprocedure costs associated with TRI were also lower in patients at greater bleeding risk.

The transradial approach. An increasingly used standard for coronary diagnosis and interventions

In the 20 years since its introduction, radial access for diagnostic and interventional coronary procedures has been well validated in countless scientific studies. Nevertheless, the use of this access route varies greatly among--and even within--countries. Fear of the unknown may make some experienced interventionalists hesitant to adopt the transradial approach in spite of its proven advantages. In our review, we describe practical aspects of the transradial access, such as the role of Allen's test in patient selection and considerations on the optimal puncture technique of the radial artery. Catheter selection, anatomic variations which may complicate access, as well as strategies to avoid and/or manage possible complications are outlined. Finally, we review the literature on the reduction of access site complications by adopting the transradial approach. Even in interventions for acute myocardial infarction, transradial access can be used safely and effectively. In addition to a reduced rate of access site complications, a reduction in overall in-hospital major adverse cardiac events has been demonstrated. The advantage regarding access site complications could be seen even when closure devices were utilized for transfemoral procedures.

Association between bleeding severity and long-term mortality in patients experiencing vascular complications after percutaneous coronary intervention

Vascular complications (VCs) occur in 3% to 8% of percutaneous coronary interventions (PCIs). However, only a portion of patients who experience VCs bleed significantly. The aim of this study was to assess the covariates associated with the amount of blood loss in patients experiencing postprocedural VCs as well as the effect of the degree of blood loss on long-term mortality. Overall, 7,718 unselected patients who underwent PCI through femoral access were evaluated. Those experiencing VCs were identified and stratified with regard to the degree of hematocrit (HCT) decrease after the procedure. In total, 444 patients (5.8%) had VCs. Compared to those without VCs, patients with VCs were older and had more extensive co-morbidities. Severe blood loss was most frequent in those who had vascular perforation requiring surgical repair or in those who had retroperitoneal bleeding. Overall, <25% of patients with hematoma had severe blood loss. The raw 1-year mortality was doubled in patients with minimal or moderate HCT decrease and was tripled in those with severe decreases in HCT. Similarly, the rate of definite stent thrombosis was tripled in patients with VCs and moderate or severe decreases in HCT. After adjustment, only patients with VCs and the greater HCT decreases had an increased risk for death at 1 year (hazard ratio 1.80, 95% confidence interval 1.03 to 3.14). Independent predictors of severe HCT decrease included age, female gender, glycoprotein IIb/IIIa inhibitor use, and activated clotting time peak. Bivalirudin and closure devices were independently associated with less frequent severe HCT decrease. In conclusion, VCs do not entail an increased risk for death at 1 year unless associated with severe blood loss. The use of bivalirudin and closure devices seems to reduce the risk for such complications.

Acute coronary syndrome: new and evolving therapies

There are many new developments in both the invasive and noninvasive treatment of ACS. As technology, pharmaceuticals, and research continue to bring new therapies to the forefront, it is essential that clinicians stay current in their understanding of how this new knowledge will impact patients and alter clinical outcomes.

Current antithrombotic agents for acute coronary syndromes: focus on bleeding risk

The formation of an intravascular thrombus underlies the clinical symptoms associated with acute coronary syndromes (ACS). Plaque rupture signals the recruitment and activation of platelets, initiation of the coagulation cascade, and generation of thrombin, resulting in the formation of a platelet-rich thrombus. Use of antithrombotic therapy, including antiplatelet and anticoagulant agents, is a crucial element in reducing the overall morbidity and mortality in patients with ACS. Current antiplatelet and anticoagulant therapies act on distinct sites in platelet activation pathways and the coagulation cascade, but because these agents target pathways necessary for protective hemostasis, their use increases the risk for bleeding complications. Previously, bleeding was considered an unavoidable side effect of ACS management with few clinical implications; however, bleeding has since been shown to be an independent predictor of short- and long-term mortality in patients with ACS. Therefore, the prevention of bleeding has become equally as important as the prevention of further ischemic events. Strategies to limit bleeding include bleeding risk stratification, appropriate dosing of antithrombotic drugs, use of the lowest dose of aspirin with proven efficacy, avoidance of combinations of antithrombotic agents unless for a proven indication, use of drugs proven to reduce the risk of bleeding, and choice of radial access over femoral access in case of invasive strategy. In this context, several novel therapeutic approaches are currently under clinical evaluation, including new antiplatelet agents, such as protease-activated receptor 1 antagonists, and new anticoagulants, such as direct-acting antagonists of factor Xa and factor IIa (thrombin). This review discusses antiplatelet and anticoagulant treatment strategies for the management of ACS, with a particular focus on their associated bleeding risks.

Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock

BACKGROUND

Intra-aortic balloon pump counterpulsation (IABP) is currently the most commonly used mechanical assist device for patients with cardiogenic shock due to acute myocardial infarction.Although there is only limited evidence by randomised controlled trials, the current guidelines of the American Heart Association/American College of Cardiology and the European Society of Cardiology strongly recommend the use of the intra-aortic balloon counterpulsation in patients with infarction-related cardiogenic shock on the basis of pathophysiological considerations as also non-randomised trials and registry data.   

OBJECTIVES

To determine the effect of IABP versus non-IABP or other assist devices guideline compliant standard therapy, in terms of efficacy and safety, on mortality and morbidity in patients with acute myocardial infarction complicated by cardiogenic shock.

SEARCH STRATEGY

Searches of CENTRAL, MEDLINE and EMBASE, LILACS, IndMed and KoreaMed, registers of ongoing trials and proceedings of conferences were conducted in January 2010, unrestricted by date. Reference lists were scanned and experts in the field contacted to obtain further information. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials on patients with myocardial infarction complicated by cardiogenic shock.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to a published protocol. Individual patient data were provided for five trials and merged with aggregate data. Summary statistics for the primary endpoints were hazard ratios (HR's) and odds ratios with 95% confidence intervals (CI).

MAIN RESULTS

Six eligible and two ongoing studies were identified from a total of 1410 references. Three compared IABP to standard treatment and three to percutaneous left assist devices (LVAD). Data from a total of 190 patients with acute myocardial infarction and cardiogenic shock were included in the meta-analysis: 105 patients were treated with IABP and 85 patients served as controls. 40 patients were treated without assisting devices and 45 patients with LVAD. HR's for all-cause 30-day mortality of 1.04 (95% CI 0.62 to 1.73) provides no evidence for a survival benefit. While differences in survival were comparable in patients treated with IABP, with and without LVAD, haemodynamics and incidences of device related complications show heterogeneous results.

AUTHORS' CONCLUSIONS

Available evidence suggests that IABP may have a beneficial effect on the haemodynamics, however there is no convincing randomised data to support the use of IABP in infarct related cardiogenic shock.

Variation in recovery: Role of gender on outcomes of young AMI patients (VIRGO) study design

BACKGROUND

Among individuals with ischemic heart disease, young women with an acute myocardial infarction (AMI) represent an extreme phenotype associated with an excess mortality risk. Although women younger than 55 years of age account for less than 5% of hospitalized AMI events, almost 16 000 deaths are reported annually in this group, making heart disease a leading killer of young women. Despite a higher risk of mortality compared with similarly aged men, young women have been the subject of few studies.

METHODS AND RESULTS

Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) is a large, observational study of the presentation, treatment, and outcomes of young women and men with AMI. VIRGO will enroll 2000 women, 18 to 55 years of age, with AMI and a comparison cohort of 1000 men with AMI from more than 100 participating hospitals. The aims of the study are to determine sex differences in the distribution and prognostic importance of biological, demographic, clinical, and psychosocial risk factors; to determine whether there are sex differences in the quality of care received by young AMI patients; and to determine how these factors contribute to sex differences in outcomes (including mortality, hospitalization, and health status). Blood serum and DNA for consenting participants will be stored for future studies.

CONCLUSIONS

VIRGO will seek to identify novel and prognostic factors that contribute to outcomes in this young AMI population. Results from the study will be used to develop clinically useful risk-stratification models for young AMI patients, explain sex differences in outcomes, and identify targets for intervention.

Incidence, correlates, and clinical impact of nuisance bleeding after antiplatelet therapy for patients with drug-eluting stents

BACKGROUND

Nuisance bleeding (NB) after dual antiplatelet therapy (DAPT) is not well characterized despite its potential to impact patient compliance. We therefore aimed to evaluate the incidence, correlates, and clinical impact of NB after DAPT after drug-eluting stent (DES) implantation.

METHODS

Included were 2,948 patients with DES implantation who were discharged on DAPT for 12 months. New bleeding classifications were used: alarming bleeding, internal bleeding, and NB.

RESULTS

After excluding patients with alarming bleeding (9 [0.3%]) and internal bleeding (128 [4.3%]), the 2,811 remaining patients were divided into 2 groups: those with NB (812 [28.9%]) and those without (1,999 [71.1%]). Patients with NB were significantly younger (63.0 +/- 11.4 vs 65.2 +/- 11.6 years, P < .001), were more often white (82.0% vs 69.6%, P < .001), had lower body mass indices (29.2 +/- 6.1 vs 29.8 +/- 6.0 kg/m(2), P = .01), and a lower prevalence of diabetes (25.5% vs 34.8%, P < .001) compared to those without NB. At 1 year, the rate of major adverse cardiac events was higher in the NB group compared to the nonbleeding group (77 [9.4%] vs 134 [6.7%], P = .02). In the NB group, 46 patients (5.7%) stopped 1 or both antiplatelet therapies. Thirty-five (4.3%) discontinued clopidogrel, 16 (2.0%) stopped aspirin, and 5 (0.61%) stopped both as a result of the reported NB. Multivariable analysis detected younger age, lower body mass index, white race, and without diabetes as correlates associated with NB while on clopidogrel therapy.

CONCLUSION

Nuisance bleeding is common in patients on prolonged DAPT post-DES implantation and can impact compliance. Nuisance bleeding appears to have important clinical implications and, if confirmed in prospective trials, should be added to the safety end points assessing new antiplatelet agents.

Hematomas of at least 5 cm and outcomes in patients undergoing elective percutaneous coronary intervention: insights from the SafeTy and Efficacy of Enoxaparin in PCI patients, an internationaL randomized Evaluation (STEEPLE) trial

BACKGROUND

Major bleeding significantly impacts outcomes in patients undergoing percutaneous coronary intervention (PCI). No uniform definitions exist for major and minor bleeding. Hematomas > or =5 cm at the femoral puncture site are considered major bleeding events in some trials and minor in others. Limited information is available on the incidence and clinical relevance of hematomas > or =5 cm in PCI patients.

METHODS

Data from the STEEPLE trial in patients undergoing elective PCI were used to assess the impact of hematomas > or =5 cm on ischemic outcomes (mortality, nonfatal myocardial infarction, or urgent target vessel revascularization) up to day 30 and all-cause 1-year mortality. Hematoma data were available for 3,342 of 3,528 patients in STEEPLE. Patients with (n = 103) and without (n = 3,239) hematomas > or =5 cm were evenly distributed across treatment groups.

RESULTS

No differences were observed in 30-day ischemic outcomes between patients with and without hematomas (5.8% vs 5.9%, respectively; P = .96). No transfusions were observed in patients with hematomas as compared with patients without hematomas (0% and 0.4%, respectively; P = .52). A greater reduction in hemoglobin was observed (pre- vs post-PCI) in patients with hematomas as compared with patients without hematomas (-0.84 vs -0.35 g/L, P < or = .001). No significant difference in all-cause 1-year mortality was observed between patients with and without hematomas (0.0% vs 1.7%, P = .98).

CONCLUSIONS

After PCI, hematomas > or =5 cm had no effect on 30-day ischemic events or 1-year mortality. Although there is no agreed classification for large hematomas, the lack of a relationship between hematomas > or =5 cm and clinical outcome after PCI justifies the classification of these hematomas as minor bleeds in STEEPLE.

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.