Incidence of bleeding in renally impaired patients receiving incorrectly dosed eptifibatide or bivalirudin while undergoing percutaneous coronary intervention

Use of Contraindicated Antiplatelet Medications in the Setting of Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

BACKGROUND

Several antiplatelet medications used during and after percutaneous coronary intervention (PCI) are contraindicated for specific patient groups. A broad assessment of contraindicated medication use and associated clinical outcomes is not well described.

METHODS AND RESULTS

Using national Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data for all PCI between 2007 and 2013, we evaluated patients with contraindications to commonly used antiplatelet medications during and after PCI, defined in accordance with package inserts. Adjusted association between contraindicated medication use and outcomes of periprocedural bleeding and 30-day mortality were assessed using Cox proportional hazards with inverse probability weighting. Among 64 294 patients undergoing PCI, 11 315(17.6%) had a contraindication to a common antiplatelet medication and 737 (6.5%) of these patients received a contraindicated medication. In unadjusted analyses, any contraindicated medication use was associated with both increased bleeding and 30-day mortality. In adjusted models, contraindicated abciximab use in patients with thrombocytopenia (hazard ratio, 2.23; 95% confidence interval, 1.58-3.16) and in patients with a previous stroke (hazard ratio, 1.93; 95% confidence interval, 1.37-2.71) remained significantly associated with increased bleeding. Contraindicated abciximab use was not significantly associated with 30-day mortality in adjusted models. Use of eptifibatide in dialysis patients was not significantly associated with an increased risk of bleeding or mortality.

CONCLUSIONS

In this national cohort, ≈18% of patients undergoing PCI had contraindications to common antiplatelet medications. Approximately 6% of those patients received a contraindicated medication with attendant bleeding risk, although this did not translate into significantly higher risk of 30-day mortality. Continued efforts to reduce contraindicated medication use may help avoid periprocedural complications.

Sources of hospital-level variation in major bleeding among patients with non-st-segment elevation myocardial infarction: a report from the National Cardiovascular Data Registry (NCDR)

BACKGROUND

Major bleeding has received increasing attention as a target for quality improvement in care of patients with acute myocardial infarction. However, little is known about variation in bleeding across hospitals and whether variation is attributable to quality of hospital care, treatments, or case mix.

METHODS AND RESULTS

We characterized hospital variation in major bleeding events (an absolute hemoglobin drop ≥4 g/dL, intracranial hemorrhage, retroperitoneal bleed, or transfusion) among 99 200 patients with non-ST-segment elevation myocardial infarction in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines (ACTIOM Registry-GWTG) between January 2007 and June 2010. A total of 9566 (9.6%) patients experienced a major bleeding event during hospitalization. The median of the estimated distribution of major bleeding rates across hospitals was 9.4% (interquartile range, 7.5%-11.7%), with some hospitals having bleeding rates >2.3 times higher than others (10th-90th percentile, 6.1%-14.2%). Multivariable hierarchical models revealed that differences in case mix explained 19.2% of the hospital variation in bleeding complications, where anticoagulation and antiplatelet strategies explained an incremental 9.9% and 6.8%, respectively. Together, 32.3% of hospital variation in major bleeding rates was attributable to differences in patient case mix and identifiable differences in treatment strategies in patients with non-ST-segment elevation myocardial infarction.

CONCLUSIONS

In-hospital major bleeding rates varied widely across hospitals. Although patient factors and treatments explained less than one third of hospital-level variation, ≈70% of bleeding variation remains after adjustment. A better understanding of causes for substantial hospital-level bleeding variations is needed to help target high-risk patients or practices and to optimize care.