Determinants of Significant Out-Of-Hospital Bleeding in Patients Undergoing Percutaneous Coronary Intervention

Sabato Sorrentino; Usman Baber; Bimmer E. Claessen; Anton Camaj; Birgit Vogel; Samantha Sartori; Paul Guedeney; Jaya Chandrasekhar; Serdar Farhan; Nitin Barman; Joseph Sweeny; Gennaro Giustino; George Dangas; Annapoorna Kini; Samin Sharma; Roxana Mehran

doi:10.1055/s-0038-1673687

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2018; 118(11): 1997-2005
DOI: 10.1055/s-0038-1673687

Atherosclerosis and Ischaemic Disease

Georg Thieme Verlag KG Stuttgart · New York

Determinants of Significant Out-Of-Hospital Bleeding in Patients Undergoing Percutaneous Coronary Intervention

Sabato Sorrentino

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

²Division of Cardiology, Department of Medical and Surgical Sciences, University Magna Graecia, Catanzaro, Italy

,

Usman Baber

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Bimmer E. Claessen

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Anton Camaj

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Birgit Vogel

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Samantha Sartori

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Paul Guedeney

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Jaya Chandrasekhar

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Serdar Farhan

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Nitin Barman

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Joseph Sweeny

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Gennaro Giustino

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

George Dangas

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Annapoorna Kini

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Samin Sharma

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

,

Roxana Mehran

¹The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States

› Author Affiliations

Abstract

Background Although several variables have been identified as bleeding determinants (BDs), their occurrence and predictive value in patients undergoing percutaneous coronary intervention (PCI) in the real world remain unclear. We aimed to characterize the rate of BDs in patients undergoing PCI with stent implantation in a large volume tertiary centre.

Methods We included patients undergoing coronary stenting at our institution from January 2012 to December 2016, and defined post-discharge bleeding (PDB) as bleeding requiring hospitalization or transfusion. Several BDs, identified by the PARIS bleeding and PRECISE-DAPT scores and inclusion criteria of the LEADERS FREE trial, were analysed.

Results In a population of 10,406 subjects who underwent PCI, 2,938 patients (28.2%) had 1, 2,367 (22.8%) had 2 and 2,913 (28.0%) had ≥3 pre-specified BD. Compared with patients without PDB, subjects who experienced PDB were older (70.43 ± 11.94 vs. 65.90 ± 11.54 years, p < 0.0001) with a higher prevalence of common cardiovascular risk factors. One-year PDB occurred in 177 patients (2.4%), and consistently increased according to the number of BDs involved (1.12, 2.11 and 4.35%, respectively; p < 0.0001). Analogously, 1-year rates of post-discharge myocardial infarction or stent thrombosis increased according to the number of BDs (2.44, 3.38 and 4.87%, respectively; p < 0.0001). Only 7 BDs remained independently associated with PDB at 1 year, with anaemia, oral anticoagulant at discharge and malignancy representing the strongest predictors of such risk.

Conclusion Many risk factors predispose to PDB; they were often clustered together and conferred additive PDB risk at 1-year of follow-up.

Keywords

coronary syndrome - ischaemic heart disease - anti-platelet agents - ADP receptors - aging

Full Text

References

References
1 Baber U, Mehran R, Giustino G. , et al. Coronary thrombosis and major bleeding after PCI with drug-eluting stents: risk scores from PARIS. J Am Coll Cardiol 2016; 67 (19) 2224-2234
2 Valgimigli M, Patialiakas A, Thury A. , et al; ZEUS Investigators. Zotarolimus-eluting versus bare-metal stents in uncertain drug-eluting stent candidates. J Am Coll Cardiol 2015; 65 (08) 805-815
3 Urban P, Meredith IT, Abizaid A. , et al; LEADERS FREE Investigators. Polymer-free drug-coated coronary stents in patients at high bleeding risk. N Engl J Med 2015; 373 (21) 2038-2047
4 Bonaca MP, Storey RF, Theroux P. , et al. Efficacy and safety of ticagrelor over time in patients with prior MI in PEGASUS-TIMI 54. J Am Coll Cardiol 2017; 70 (11) 1368-1375
5 Eikelboom JW, Connolly SJ, Bosch J. , et al; COMPASS Investigators. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med 2017; 377 (14) 1319-1330
6 Baber U. Predicting risk for bleeding after PCI: another step in the right direction but work remains. Int J Cardiol 2018; 254: 45-46
7 Ariotti S, Adamo M, Costa F. , et al; ZEUS Investigators. Is bare-metal stent implantation still justifiable in high bleeding risk patients undergoing percutaneous coronary intervention? A pre-specified analysis from the ZEUS trial. JACC Cardiovasc Interv 2016; 9 (05) 426-436
8 Costa F, van Klaveren D, James S. , et al; PRECISE-DAPT Study Investigators. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet 2017; 389 (10073): 1025-1034
9 Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. ; Writing Group on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. Glob Heart 2012; 7 (04) 275-295
10 Cutlip DE, Windecker S, Mehran R. , et al; Academic Research Consortium. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 2007; 115 (17) 2344-2351
11 Yeh RW, Secemsky EA, Kereiakes DJ. , et al; DAPT Study Investigators. Development and validation of a prediction rule for benefit and harm of dual antiplatelet therapy beyond 1 year after percutaneous coronary intervention. JAMA 2016; 315 (16) 1735-1749
12 Raposeiras-Roubín S, Faxén J, Íñiguez-Romo A. , et al. Development and external validation of a post-discharge bleeding risk score in patients with acute coronary syndrome: the BleeMACS score. Int J Cardiol 2018; 254: 10-15
13 Park SK, Jung DE, Jung SA, Kim WH, Bahk JH. Risk of non-cardiac surgery after percutaneous coronary intervention with drug-eluting stents. Sci Rep 2017; 7 (01) 16393
14 Schoos M, Chandrasekhar J, Baber U. , et al. Causes, timing, and impact of dual antiplatelet therapy interruption for surgery (from the Patterns of Non-adherence to Anti-platelet Regimens in Stented Patients Registry). Am J Cardiol 2017; 120 (06) 904-910
15 Bucholz EM, Krumholz HA, Krumholz HM. Underweight, markers of cachexia, and mortality in acute myocardial infarction: a prospective cohort study of elderly Medicare beneficiaries. PLoS Med 2016; 13 (04) e1001998
16 Park CS, Choi EK, Kim HM, Lee SR, Cha MJ, Oh S. Increased risk of major bleeding in underweight patients with atrial fibrillation who were prescribed non-vitamin K antagonist oral anticoagulants. Heart Rhythm 2017; 14 (04) 501-507
17 Faggioni M, Baber U, Afshar AE. , et al. Effects of body mass index on clinical outcomes in female patients undergoing percutaneous coronary intervention with drug-eluting stents: results from a patient-level pooled analysis of randomized controlled trials. JACC Cardiovasc Interv 2018; 11 (01) 68-76
18 Baber U, Chandrasekhar J, Sartori S. , et al. Associations between chronic kidney disease and outcomes with use of prasugrel versus clopidogrel in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a report from the PROMETHEUS study. JACC Cardiovasc Interv 2017; 10 (20) 2017-2025
19 Baber U, Li SX, Pinnelas R. , et al. Incidence, patterns, and impact of dual antiplatelet therapy cessation among patients with and without chronic kidney disease undergoing percutaneous coronary intervention: results from the PARIS Registry (Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients). Circ Cardiovasc Interv 2018; 11 (03) e006144
20 Sorrentino S, Iaconetti C, De Rosa S. , et al. Hindlimb ischemia impairs endothelial recovery and increases neointimal proliferation in the carotid artery. Sci Rep 2018; 8 (01) 761
21 Kannel WB. Risk stratification in hypertension: new insights from the Framingham Study. Am J Hypertens 2000; 13 (1 Pt 2): 3S-10S

Supplementary Material

Supplementary Material