Stopping the Hemorrhage

Abstract

Aggressive management of high-risk non–ST-elevation acute coronary syndrome patients has focused on reducing ischemic complications with potent medications and mechanical interventions1,2 but at the cost of increased rates of major bleeding and associated adverse outcomes.3,4 The American College of Cardiology/American Heart Association 2007 guidelines for management of patients with unstable angina/non–ST-elevation myocardial infarction (NSTEMI)1 stress the importance of balancing antithrombotic and interventional therapies with therapeutic risk, and they urge special attention in groups at high bleeding risk, including women, the elderly, and those with renal insufficiency. For risk-prone groups, careful selection and dose adjustment of antithrombotics is encouraged, but no specific instruction for calculating bleeding risk or modifying treatment is provided. Article p 1873 The European Society of Cardiology’s 2007 guidelines for the diagnosis and treatment of non–ST-segment elevation acute coronary syndromes2 also recognize and devote a special section to bleeding complications, covering predictors of bleeding risk, the impact of bleeding on prognosis, the management of bleeding complications, and the impact of blood transfusions on outcomes. Major bleeding has been reported in 2% to 8% of non–ST-elevation acute coronary syndrome patients, with higher rates noted in broad-based registries (as in CRUSADE: Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the ACC/AHA guidelines) than in controlled clinical trials. Complicating therapeutic decision making is the observation that baseline predictors of bleeding, ie, old age, female sex, renal dysfunction, and baseline anemia, also predict the risk of death due to ischemic complications. The impact of bleeding on prognosis is increasingly recognized. Major bleeding in the Global Registry of Acute Coronary Events (GRACE) was significantly associated with in-hospital death (adjusted OR 1.645). In registries and trials of more than 30 000 patients, major bleeding was associated with a 4-fold increase in the …