Impact of Major Bleeding on 30-Day Mortality and Clinical Outcomes in Patients With Acute Coronary Syndromes: An Analysis From the ACUITY Trial

Abstract

Impact of Major Bleeding on 30-Day Mortality and Clinical Outcomes in Patients With Acute Coronary Syndromes: An Analysis From the ACUITY Trial Steven V. Manoukian, Frederick Feit, Roxana Mehran, Michele D. Voeltz, Ramin Ebrahimi, Martial Hamon, George D. Dangas, A. Michael Lincoff, Harvey D. White, Jeffrey W. Moses, Spencer B. King III, E. Magnus Ohman, Gregg W. Stone The predictors of major bleeding and its impact on 30-day mortality in 13,819 patients with acute coronary syndromes (ACS) undergoing an early invasive strategy were assessed. Major bleeding occurred in 4.7% of patients and was less frequent with the use of bivalirudin monotherapy versus heparin (unfractionated or enoxaparin) plus glycoprotein IIb/IIIa inhibition (3.0% vs. 5.7%, p < 0.0001). Several factors were independent predictors of major bleeding, including treatment with heparin plus glycoprotein IIb/IIIa inhibition. Major bleeding was a powerful independent predictor of 30-day mortality (odds ratio 7.55, 95% confidence interval 4.68 to 12.18, p < 0.0001). Reducing bleeding risk might improve outcomes in ACS. The purpose of this study was to determine the predictors of major bleeding and the impact of major bleeding on outcomes, including mortality, in acute coronary syndromes (ACS). Whether major bleeding independently predicts mortality in patients with ACS undergoing an early invasive strategy is undefined. Patients (n = 13,819) with moderate- and high-risk ACS were randomized to heparin (unfractionated or enoxaparin) plus glycoprotein IIb/IIIa inhibition (GPI), bivalirudin plus GPI, or bivalirudin monotherapy (plus provisional GPI). Logistic regression was used to determine predictors of 30-day major bleeding and mortality. Major bleeding rates in patients treated with heparin plus GPI were higher versus bivalirudin monotherapy (5.7% vs. 3.0%, p < 0.001) and similar versus bivalirudin plus GPI (5.7% vs. 5.3%, p = 0.38). Independent predictors of major bleeding were advanced age, female gender, diabetes, hypertension, renal insufficiency, anemia, no prior percutaneous coronary intervention, cardiac biomarker elevation, ST-segment deviation ≥1 mm, and treatment with heparin plus GPI versus bivalirudin monotherapy. Patients with major bleeding had higher 30-day rates of mortality (7.3% vs. 1.2%, p < 0.0001), composite ischemia (23.1% vs. 6.8%, p < 0.0001), and stent thrombosis (3.4% vs. 0.6%, p < 0.0001) versus those without major bleeding. Major bleeding was an independent predictor of 30-day mortality (odds ratio 7.55, 95% confidence interval 4.68 to 12.18, p < 0.0001). Major bleeding is a powerful independent predictor of 30-day mortality in patients with ACS managed invasively. Several factors independently predict major bleeding, including treatment with heparin plus GPI compared with bivalirudin monotherapy. Knowledge of these findings might be useful to reduce bleeding risk and improve outcomes in ACS.