Bleeding In Percutaneous Coronary Intervention Research Articles

Low-density lipoprotein cholesterol levels and long-term bleeding in patients undergoing percutaneous coronary intervention: 5-year outcomes from a large cohort study

Abstract Aims Recent research reported that lower low-density lipoprotein cholesterol (LDL-C) is associated with more in-hospital bleeding in acute coronary syndrome (ACS) patients. However, the association between lower LDL-C levels and long-term bleeding in percutaneous coronary intervention (PCI) patients remains unclear. Methods A total of 10724 patients treated with PCI enrolled in ourhospital from January 2013 to December 2013. The primary endpoint was the Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding at 5 years. The secondary endpoint was intracranial hemorrhage. Taking the LDL-C value of 1.8 mmol/L (70 mg/dL) or 1.4 mmol/L (55 mg/dL) as cut-off points, patients were grouped to analyse, respectively. Results Among 9697 PCI patients treated with dual antiplatelet therapy finally enrolled, a total of 411 BARC type 2, 3 or 5 bleedings and 42 intracranial hemorrhage were recorded during a follow-up of 5 years. With LDL-C value of 1.8 mmol/L as cut-off point, multivariate Cox regression showed that lower LDL-C level was not associated with the risk for bleeding [hazard ratio (HR): 1.166, 95% confidence interval (CI): 0.879–1.549]. The result was consistent (HR: 1.185; 95% CI: 0.713–1.968) in a 1:4 propensity-score matching cohort (n=1285). For further study, we performed subgroup analysis which showed that lower LDL-C was not associated with the risk for bleeding in ACS (HR: 1.140; 95% CI: 0.846–1.535) or non-ACS patients (HR: 1.284; 95% CI: 0.909–1.813). With LDL-C value of 1.4 mmol/L as cut-off point, Cox regression showed that lower LDL-C level was not associated with the risk for bleeding in total population, ACS or non-ACS patients (P>0.05). The result was consistent in a 1:4 propensity-score matching cohort (n=760) (P>0.05). As for secondary endpoint, lower LDL-C level was not associated with the risk for intracranial hemorrhage whether the LDL-C value is 1.8 or 1.4 mmol/L as the cut-off point (P>0.05). Conclusions To the best of our knowledge, we firstly report lower LDL-C level (whether the LDL-C value is 1.8 or 1.4 mmol/L as the cut-off point) was not the independent risk factor of long-term bleeding in PCI population and ACS or non-ACS subgroup populations. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): CAMS Innovation Fund for Medical Sciences (CIFMS); Young and middle-aged talents in the XPCC Science and Technology Project

In-hospital Outcome of Percutaneous Coronary Intervention among Very Elderly Patients with Ischemic Heart Disease in a Dedicated Cardiac Hospital

Background: Cardiovascular disease, and ischemic heart disease (IHD), is a major cause of morbidity and mortality in the very elderly patients (>80 years) worldwide. These patients represent a rapidly growing cohort presenting for percutaneous coronary intervention (PCI), now constituting more than one in five patients treated with PCI in real-world practice. Furthermore, they often have greater ischemic burden than their younger counterparts, suggesting that they have greater scope of benefit from coronary revascularization therapy. The elderly usually has higher prevalence of co morbidities and more often experience complications during and after revascularization procedures. Our aim was to evaluate clinical outcomes of PCI in patients older than 80 years, compared to their younger counterparts.
 Materials and methods: From July 2017 to July 2018 we included 212 patients with IHD purposively in Cardiology department of National Institute of Cardiovascular Diseases undergone PCI who were divided into 2 groups according to age: e” 80 years (n = 74) and < 80 years (n = 138). Baseline clinical characteristics, indications for coronary intervention, in hospital outcomes were obtained. Study endpoint were Renal impairment, MI, LVF, emergency revascularization and death.
 Results: Very elderly patients were more frequently male (86%) and nonsmoker at present (41% vs. 63%, p=0.003), had higher prevalence of hypertension (60% vs. 50%, p<0.13), and more often presented with NSTEMI (54% vs. 23%, p<0.001). Elderly group had higher incidence of TVD and LM disease (36% vs. 26% and 9.5% vs. 2.9%, p=0.07) and more incidence of ostial (16.2% vs.5.1%,p=0.007) and calcified lesions (31.1% vs. 14.5%, p=0.004). Procedural success (TIMI III) were high in both groups, but still lower in the elderly as compared to younger group (95% vs. 97%, p=0.65). Very elderly patients had higher incidence of post PCI bleeding, CIN, MI, LVF and death (9.5% vs.6.1%, 8.2% vs.3.7%, 6.8% vs.5.8%, 9.5% vs. 5.1% and 5.4%vs.3.6%,p=0.07), whereas emergency revascularization were higher in younger group (5.4% vs. 6.5%, p=0.07).
 Conclusion: Very elderly patients aged ≥80 years face more vascular site complications during PCI, usually have more LM and TVD with more ostial and calcified lesions in comparison with younger group. Though procedural success is similar with younger group, they face more post PCI CIN, LVF and MI. Repeat revascularization was higher in younger group.
 Bangladesh Heart Journal 2020; 35(1) : 61-65

Clinical Outcomes of Percutaneous Coronary Intervention in Octogenarians

Background: Octogenarians are high risk patients and largely under-represented in clinical trials. The use of evidence-based therapy is, therefore, lower in this age group, resulting in a reliance on non-evidence based decision making. The elderly usually have higher prevalence of co morbidities and more often experience complications during and after revascularization procedures.Methods: 212 patients with ischemic heart disease who underwent percutaneous coronary intervention (PCI) were divided into 2 groups according to age: ³80 years (n = 74) and < 80 years (n = 138). Baseline clinical characteristics, indications for coronary intervention, in hospital outcomes and 1 year outcome were obtained. Study endpoint was in hospital outcome (Renal impairment, MI, LVF, emergency revascularization, death) & 1 year follow up for myocardial infarction (MI), repeat revascularization and death.Results: Procedural success (TIMI III) were high in both groups, but still lower in the elderly as compared to younger group (95% vs. 97%, p=0.65).The elderly had higher incidence of post PCI bleeding, contrast induced nephropathy (CIN), MI, left ventricular failure (LVF) and death (9.5% vs.6.1%, 8.2% vs.3.7%, 6.8% vs.5.8%, 9.5% vs. 5.1% and 5.4%vs.3.6%, p=0.07). Whereas emergency revascularization were higher in younger group (5.4% vs. 6.5%, p=0.07). At 1 year MI and death were higher in elderly group (9.5% vs.6.5%, 6.8% vs.6.5% p=0.66), whereas repeat revascularization were higher in younger group (6.8% vs.8%, p= 0.66).Conclusion: Though immediate interventional procedure related complications are more in octogenarians, long term outcomes seem to be promising & comparable with younger counterparts.Cardiovasc. j. 2018; 10(2): 121-125

Comparison of Bleeding Outcomes After Percutaneous Coronary Intervention in Patients With Versus Without Aortic Stenosis

Aortic stenosis (AS) is associated with an increased risk of bleeding, but little is known about the risk of bleeding during percutaneous coronary intervention (PCI) in patients with AS. In the era of transcutaneous aortic valve implantation, understanding the bleeding risks associated with AS is critical. This retrospective study included 7,926 patients who underwent PCI from 2004 to 2013. Patients were categorized according to the presence of significant AS: moderate or severe AS (n= 354) and mild or no AS (n= 7,572). The National Cardiovascular Data Registry (NCDR) definition of a bleeding event (transfusion, prolonged hospital stay, or decrease in hemoglobin >3.0mg/dl) was used as the primary outcome, and the NCDR PCI Bleeding Risk Score was used to control for the underlying risk of bleeding because of baseline characteristics. Patients with AS had significantly higher NCDR PCI Bleeding Risk Scores and higher rates of bleeding events. Logistic regression showed that the NCDR PCI Bleeding Risk Score did predict bleeding outcomes. There was not, however, an independent association between AS and bleeding outcomes. The addition of AS to the risk score using net reclassification improvement did not enhance the model's ability to predict bleeding (p= 0.71). These data suggest that the NCDR PCI Bleeding Risk Score appropriately adjusts for bleeding risks in patients with AS. In conclusion, although patients with AS are more likely to have bleeding complications after PCI, the increased risk of bleeding is driven by the patients' baseline co-morbidities rather than their AS.

Validity of a PCI Bleeding Risk Score in patient subsets stratified for body mass index

ObjectiveAn accurate tool with good discriminative for bleeding would be useful to clinicians for improved management of all their patients. Bleeding risk models have been published but not externally validated...

Comparison of Bivalirudin and Radial Access Across a Spectrum of Preprocedural Risk of Bleeding in Percutaneous Coronary Intervention

Background— Bleeding is a common, noncardiac, preventable complication of percutaneous coronary intervention. We compared the relative safety of radial access and bivalirudin in percutaneous coronary intervention. Methods and Results— From CathPCI Registry, we determined the association between the site of arterial access, bivalirudin, and periprocedural bleeding rates in 501 017 patients. Radial access patients receiving heparin (radial group) were compared with those receiving bivalirudin (radial combination group). Femoral access patients who had bivalirudin and a vascular closure device served as a reference group (femoral group). An inverse probability weighting analysis incorporating propensity scores was used to compare groups. The overall rate of bleeding was 2.59%. It was 2.71% in the femoral group, 2.5% in the radial group, and 1.82% in the radial combination groups ( P <0.001). When compared with femoral group, the adjusted odds ratio for bleeding was significantly lower for patients with radial combination group (odds ratio, 0.79; 95% confidence interval, 0.72–0.86), but not for radial group (odds ratio, 0.96; 95% confidence interval, 0.88–1.05), unless patients treated with IIb/IIIa were excluded (radial group-IIb/IIIa odds ratio, 0.84; 95% confidence interval, 0.75–0.94).The number needed to treat to prevent 1 bleeding event with radial combination group was 138, whereas the number needed to treat to prevent 1 bleeding event in high-bleeding risk patients was 68. Conclusions— In this observational analysis, the combination of bivalirudin and radial access was associated with reduced bleeding event rate. This benefit was present across the entire spectrum of preprocedural risk of bleeding, with or without exposure to IIb/IIIa inhibitors. These data support an adequately powered randomized trial comparing bleeding avoidance strategies.

Benefit of Bivalirudin Versus Heparin After Transradial and Transfemoral Percutaneous Coronary Intervention

Bivalirudin, a direct thrombin inhibitor, has been shown to reduce major bleeding and provide a better safety profile compared to unfractionated heparin (UFH) in patients undergoing percutaneous coronary intervention (PCI) through transfemoral access. Data pertaining to the clinical benefit of bivalirudin compared to UFH monotherapy in patients undergoing transradial PCI are lacking. The present study sought to compare the in-hospital net clinical adverse events, including death, myocardial infarction, target vessel revascularization, and bleeding, for these 2 antithrombotic regimens for all patients at a tertiary care, high-volume radial center. From April 2009 to February 2011, all patients treated with bivalirudin were matched by access site to those receiving UFH. The patients in the bivalirudin group (n = 125) were older (72 ± 13 years vs 66 ± 11 years; p <0.0001), more often had chronic kidney disease (51% vs 30%; p = 0.0012), and more often underwent primary PCI (30% vs 14%, p <0.0037) than the UFH-treated patients (n = 125). A radial approach was used in 71% of both groups. The baseline bleeding risk according to Mehran's score was similar in both groups (14 ± 9 vs 15 ± 8, p = 0.48). In-hospital mortality was 2% in both groups (p = 1.00). No difference in net clinical adverse events or ischemic or bleeding complications was detected between the 2 groups. Bivalirudin reduced both ischemic and bleeding events in femoral-treated patients, but no such clinical benefit was observed in the radial-treated patients. In conclusion, as periprocedural PCI bleeding avoidance strategies have become paramount to optimize the clinical benefit, the interaction between bivalirudin and radial approach deserves additional investigation.

Incidence, Prognostic Impact, and Influence of Antithrombotic Therapy on Access and Nonaccess Site Bleeding in Percutaneous Coronary Intervention

The aim of this study was to evaluate the relative frequency of access and nonaccess site bleeding, the association of these events with 1-year mortality, and the impact of randomized antithrombotic therapy. Post-percutaneous coronary intervention (PCI) bleeding has been strongly associated with subsequent mortality. The extent to which access versus nonaccess site bleeding contributes to this poor prognosis and the role of antithrombotic therapies remains poorly understood. The incidence and impact of Thrombolysis In Myocardial Infarction (TIMI) major/minor 30-day bleeding and randomized antithrombotic therapy were examined in a combined dataset from the REPLACE-2 (Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events), Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY), and HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trials in 17,393 PCI patients. The TIMI major/minor bleeding occurred in 5.3% of patients, 61.4% of which (3.3%) were nonaccess site bleeds. After multivariable adjustment, TIMI bleeding was associated with an increased risk of 1-year mortality (hazard ratio [HR]: 3.17, 95% confidence interval [CI]: 2.51 to 4.00, p < 0.0001). The HR of a nonaccess site bleed was approximately 2-fold that of an access site bleed: HR: 3.94, 95% CI: 3.07 to 5.15, p < 0.0001 versus HR: 1.82, 95% CI: 1.17 to 2.83, p = 0.008, respectively. Randomization to bivalirudin versus heparin + a glycoprotein IIb/IIIa inhibitor resulted in 38% and 43% relative reductions in TIMI major/minor and TIMI major bleeding, respectively (p < 0.0001 for both), with significant reductions in both access and nonaccess site bleeding. Nonaccess site bleeding after PCI is common, representing approximately two-thirds of all TIMI bleeding events, and is associated with a 4-fold increase in 1-year mortality. Use of bivalirudin rather than heparin + a glycoprotein IIb/IIIa inhibitor significantly decreases both nonaccess site as well as access site bleeding events by approximately 40%.

Gastrointestinal Bleeding in Percutaneous Coronary Intervention and Acute Coronary Syndromes

The increasingly prevalent use of antithrombotic drug combinations and an aging population are resulting in growing rates of gastrointestinal bleeding (GIB). GIB is a serious condition in the setting of stable and acute coronary syndromes, associated with high rates of ischemic events. Physicians should be aware of GIB in high-risk populations, especially the elderly and patients with anemia. We discuss the risk of GIB in patients treated with different antiplatelet and antithrombotic medications and their combinations, factors associated with GIB, and its optimal management and prevention.

Evolution of Anticoagulant and Antiplatelet Therapy: Benefits and Risks of Contemporary Pharmacologic Agents and Their Implications for Myonecrosis and Bleeding in Percutaneous Coronary Intervention

Periprocedural myonecrosis, as evidenced by elevated creatine kinase-myocardial bound (CK-MB) levels, occurs in up to 25% of patients undergoing percutaneous coronary intervention (PCI) and has been linked with an increased risk of adverse short- and long-term clinical outcomes. Such myonecrosis arises from three main pathophysiological mechanisms: procedure-related complications, lesion-specific characteristics (e.g., large thrombus burden, plaque volume), and patient-specific characteristics (e.g., genetic predisposition, arterial inflammation). Periprocedural myonecrosis has not been definitively identified as the cause of postprocedural ischemic events, although agents that reduce or prevent thrombosis--including aspirin, thienopyridines, heparin, low-molecular-weight heparins, glycoprotein IIb/IIIa inhibitors, and direct thrombin inhibitors--have been shown to reduce the incidence of ischemic outcomes in this population, as have agents that reduce inflammation (aspirin, statins). At the same time, antithrombotic agents are known to increase the risk of bleeding and the use of transfusions, which have likewise been associated with worse outcomes in these patients. Thus, optimal management of patients undergoing PCI represents a balance between minimizing the risk of ischemic outcomes and simultaneously minimizing the risk of major bleeding. It may be that patients who have only minor, untreated postprocedural elevations in CK-MB level (with no clinical or angiographic signs of ischemia) might have a better prognosis than patients who have normal CK-MB levels but who suffer major bleeding complications.

Clinical challenges of bleeding in percutaneous coronary intervention.

Clinical challenges of bleeding in percutaneous coronary intervention.