Bleeding Is Bad…. Isn’t It?

Abstract

Advances in antithrombin and antiplatelet therapy have traditionally been associated with reductions in myocardial infarction and other thrombotic events in patients who have experienced an acute coronary syndrome (ACS), are undergoing a percutaneous coronary intervention (PCI), or are receiving long-term therapy for secondary prevention of stable vascular disease. Although individual trials of antithrombotic therapy have rarely been able to demonstrate that the reduction in ischemic events leads to a reduction in mortality (the most important end point), meta-analyses have often suggested that this is the case.1 And because myocardial infarction is an independent correlate of mortality, a link between a reduction in ischemic events and reduced mortality makes intuitive sense. Article p 2793 Unfortunately, more potent anticoagulants and antiplatelet agents are also associated with an increased risk of bleeding, especially when used in combination with one another, as is usually the case. Furthermore, there is a well-established body of evidence that indicates an association between bleeding and ischemic events.2,3 It has been unclear, however, whether the link between bleeding and thrombosis is the result of bleeding after the initial development of a thrombotic complication (and its treatment) or if bleeding precedes the development of an ischemic complication and actually leads to (actually causes) thrombosis. In support of the former possibility is that patients who, because of the presence of thrombus, undergo a longer or more complicated procedure, receive a higher dose or longer duration of antithrombotic medication, or require an intra-aortic balloon pump are surely more prone to bleed. However, the possibility that hemorrhage actually leads to thrombosis rather than results from it is supported by the observation that hemorrhage is a potent stimulus for thrombosis; all patients would surely die if bleeding did not trigger at least a local thrombotic reaction. Furthermore, as the Global Registry of …