ASSOCIATION OF MAJOR BLEEDING AND BLEEDING AVOIDANCE STRATEGIES WITH IN-HOSPITAL OUTCOMES AMONG ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION PATIENTS RECEIVING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Abstract

Major bleeding is an independent predictor of mortality, reinfarction, and stroke among ST-elevation myocardial infarction (STEMI) patients receiving primary percutaneous coronary intervention (pPCI). Limited data exists on the association of major bleeding post-PCI and other significant in-hospital outcomes. Furthermore, bleeding avoidance strategies (BAS) such as radial access and bivalirudin are associated with reductions in major bleeding but the impact on the reduction of other in-hospital adverse events has not been reported. We identified 1494 STEMI patients who underwent primary pPCI within the Vancouver Coastal Health Authority (2012-2018) of whom 121 (8.1%) had major bleeding. Access site bleeding occurred in 2.0% whereas non-access site bleeding occurred in 6.1%. Between-group differences in (unadjusted) in-hospital clinical outcomes including cardiac arrest, reinfarction, stroke, cardiogenic shock, heart failure, and mortality were assessed. Spearman correlation and multivariate logistic regression were used to evaluate the relationship of major bleeding with in-hospital outcomes. Compared with no major bleeding, patients experiencing major bleeding were more likely to be female, older, have atrial fibrillation, chronic kidney disease, anemia, heart failure, prehospital cardiac arrest or cardiogenic shock at baseline. Major bleeding was associated with higher rates of in-hospital death (20.7% vs. 4.4%; P < 0.001), stroke or intracranial hemorrhage (10.8% vs 1.1%; P < 0.001), cardiogenic shock (38.3 vs 6.3%; P < 0.001), heart failure (40.8% vs. 12.0%; P < 0.001), or cardiac arrest post-PCI (20.0 vs 3.5%; P < 0.001). Major bleeding was also associated with a significantly longer hospital stay (median 7.8. vs 3.0 days; P < 0.001). Major bleeding was independently associated with death (OR 3.15; 95% CI 1.59-6.25), cardiogenic shock (OR 8.10; 95% CI 4.46-14.72), heart failure (OR 3.43; 95% CI 2.09-5.63), and in-hospital cardiac arrest post-PCI (OR 4.19; 95% CI 2.21-7.94). The use of any BAS (radial access, bivalirudin, vascular closure device) was associated with a reduction in major bleeding (OR 0.49; 95% CI 0.32-0.74) and mortality (OR 0.20; 95% CI 0.13 to 0.32) but after adjustment did not reduce major bleeding (OR 0.68; 95% CI 0.43-1.07) or mortality (OR 0.63; 95% CI 0.33-1.20). In a contemporary STEMI cohort receiving pPCI, major bleeding was predominately caused by non-access site bleeding and was independently associated with in-hospital mortality, cardiogenic shock, heart failure, and cardiac arrest post-PCI. After adjustment, BAS were not associated with a reduction in major bleeding nor in-hospital mortality, likely due to low rates of access-site bleeding. Additional study of strategies to reduce the incidence or impact of non-access site bleeding appears warranted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)