Women, Bleeding, and Coronary Intervention

Abstract

Bleeding initiates a cascade of events that increase morbidity and mortality among patients undergoing percutaneous coronary intervention (PCI).1–5 Acute loss of blood impacts circulatory volume and can potentiate and perpetuate shock. In addition, bleeding leads to anemia and transfusion of blood products, which promote inflammation and untoward cardiovascular effects, especially in the setting of acute coronary syndrome.6–8 Finally, bleeding results in cessation of dual antiplatelet therapy, which increases risk of recurrent ischemic events such as stent thrombosis and myocardial infarction.9,10 Registries and randomized trials have shown the impact of bleeding on outcomes. Patient in the Global Registry of Acute Coronary Events were noted to have a 4.0% incidence of major bleeding across the spectrum of acute coronary syndrome (ACS). Furthermore, major bleeding was an independent predictor of in-hospital mortality (adjusted odds ratio, 1.64 [95% confidence interval, 1.18-2.28]).11 Ndrepepa et al2 evaluated 4 randomized control trials of patients undergoing PCI and identified major bleeding as the strongest independent predictor of 1-year mortality. Similarly, Mehran et al12 performed a patient level pooled analysis of >17 000 patients in 3 ACS trials: the occurrence of a major bleed within 30 days of hospitalization was associated with a 4-fold higher risk of mortality at 1 year. Finally, in patients with ST segment elevation myocardial infarction enrolled in the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction trial, bleeding related to PCI was an independent predictor of mortality after 3 years of follow-up (hazard ratio, 2.80 [95% confidence interval, 1.89–4.16]).13 Increased focus on the morbidity and mortality associated with PCI-related bleeding has led to pharmacological, procedural, and technological advances,14 which have resulted in improvement in post-PCI bleeding rates over the past decade (Figure 1).15–18 The …