TY - JOUR
T1 - Prognostic significance of bleeding location and severity among patients with acute coronary syndromes
AU - Vavalle, John P.
AU - Clare, Robert
AU - Chiswell, Karen
AU - Rao, Sunil V.
AU - Petersen, John L.
AU - Kleiman, Neal S.
AU - Mahaffey, Kenneth W.
AU - Wang, Tracy Y.
N1 - Funding Information:
This project was supported by grant #U19HS021092 from the Agency for Healthcare Research and Quality . The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Dr. Rao has reported that he has received consulting fees from Terumo, ZOLL, The Medicines Company, and AstraZeneca and research funding from sanofi-aventis and Ikaria . Dr. Petersen has reported that he has received a research grant from Abbott Vascular, Medtronic, Edwards Lifesciences. Dr. Mahaffey has reported that he has received consulting fees from AstraZeneca, Daiichi Sankyo, Johnson & Johnson, Bayer HealthCare, Boehringer-Ingleheim, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Merck & Co., Inc., Novartis, Pfizer, Inc., Polymedix, and sanofi-aventis and grant support from AstraZeneca, Bayer, Boehringer-Ingleheim, Bristol-Myers Squibb, Daiichi Sankyo, Eli Lilly, GlaxoSmithKline, Merck & Co., Inc., Novartis, Pozen, Regado Biotechnologies, sanofi-aventis, Schering-Plough, and The Medicines Company. Dr. Wang has reported that she has received research funding from AstraZeneca, Bristol-Myers Squibb, Gilead Sciences, Heartscape Technologies, Inc., Lilly, sanofi-aventis, Schering-Plough, and The Medicines Company and consulting fees from the American College of Cardiology and Medco. All the other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
PY - 2013/7
Y1 - 2013/7
N2 - Objectives This study sought to determine if there is an association between bleed location and clinical outcomes in acute coronary syndromes (ACS) patients. Background The prognostic significance of bleeding location among ACS patients undergoing cardiac catheterization is not well known. Methods We analyzed in-hospital bleeding events among 9,978 patients randomized in the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) study. Bleeding events were categorized by location as access site, systemic, surgical, or superficial, and severity was graded using the GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definition. We assessed the association of each bleeding location and severity with 6-month risk of death or myocardial infarction using a multicovariate-adjusted Cox proportional hazard model. Results A total of 4,900 bleeding events were identified among 3,694 ACS patients with in-hospital bleeding. Among 4,679 GUSTO mild/moderate bleeding events, only surgical and systemic bleeds were associated with an increased risk of 6-month death or myocardial infarction (adjusted hazard ratio [HR]: 2.52 [95% confidence interval (CI): 2.16 to 2.94, and 1.40 [95% CI: 1.16 to 1.69], respectively). Mild/moderate superficial and access-site bleeds were not associated with downstream risk (adjusted HR: 1.17 [95% CI: 0.97 to 1.40], and 0.96 [95% CI: 0.82 to 1.12], respectively). Among 221 GUSTO severe bleeds, surgical bleeds were associated with the highest risk (HR: 5.27 [95% CI: 3.80 to 7.29]), followed by systemic (HR: 4.48 [95% CI: 2.98 to 6.72]), and finally access-site bleeds (HR: 3.57 [95% CI: 2.35 to 5.40]). Conclusions Among ACS patients who develop in-hospital bleeding, systemic and surgical bleeding are associated with the highest risks of adverse outcomes regardless of bleeding severity. Although the most frequent among bleeds, GUSTO mild/moderate access-site bleeding is not associated with increased risk. These data underscore the importance of strategies to minimize overall bleeding risk beyond vascular access site management.
AB - Objectives This study sought to determine if there is an association between bleed location and clinical outcomes in acute coronary syndromes (ACS) patients. Background The prognostic significance of bleeding location among ACS patients undergoing cardiac catheterization is not well known. Methods We analyzed in-hospital bleeding events among 9,978 patients randomized in the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) study. Bleeding events were categorized by location as access site, systemic, surgical, or superficial, and severity was graded using the GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) definition. We assessed the association of each bleeding location and severity with 6-month risk of death or myocardial infarction using a multicovariate-adjusted Cox proportional hazard model. Results A total of 4,900 bleeding events were identified among 3,694 ACS patients with in-hospital bleeding. Among 4,679 GUSTO mild/moderate bleeding events, only surgical and systemic bleeds were associated with an increased risk of 6-month death or myocardial infarction (adjusted hazard ratio [HR]: 2.52 [95% confidence interval (CI): 2.16 to 2.94, and 1.40 [95% CI: 1.16 to 1.69], respectively). Mild/moderate superficial and access-site bleeds were not associated with downstream risk (adjusted HR: 1.17 [95% CI: 0.97 to 1.40], and 0.96 [95% CI: 0.82 to 1.12], respectively). Among 221 GUSTO severe bleeds, surgical bleeds were associated with the highest risk (HR: 5.27 [95% CI: 3.80 to 7.29]), followed by systemic (HR: 4.48 [95% CI: 2.98 to 6.72]), and finally access-site bleeds (HR: 3.57 [95% CI: 2.35 to 5.40]). Conclusions Among ACS patients who develop in-hospital bleeding, systemic and surgical bleeding are associated with the highest risks of adverse outcomes regardless of bleeding severity. Although the most frequent among bleeds, GUSTO mild/moderate access-site bleeding is not associated with increased risk. These data underscore the importance of strategies to minimize overall bleeding risk beyond vascular access site management.
KW - acute coronary syndrome
KW - bleeding
KW - percutaneous coronary intervention
UR - http://www.scopus.com/inward/record.url?scp=84880322920&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84880322920&partnerID=8YFLogxK
U2 - 10.1016/j.jcin.2013.03.010
DO - 10.1016/j.jcin.2013.03.010
M3 - Article
C2 - 23866183
AN - SCOPUS:84880322920
SN - 1936-8798
VL - 6
SP - 709
EP - 717
JO - JACC: Cardiovascular Interventions
JF - JACC: Cardiovascular Interventions
IS - 7
ER -