Higher Bleeding Rates Research Articles

Gastrointestinal bleeding

Interest in technical developments related to small-bowel imaging has been reflected in the number of abstracts dealing with the use of capsule endoscopy and double-balloon enteroscopy in gastrointestinal bleeding; the enthusiasm is still growing. For peptic ulcer bleeding, the surprisingly still high rates of recurrent bleeding, in spite of technological advances, still motivates clinicians to study the various factors that may influence the outcome and determine the way in which centers can adhere to practices that are based on the best available evidence. Concerns relating to the outcome of glue injection for bleeding gastric varices appear to be unjustified so far. There are still uncertainties relating to the endoscopic diagnosis and treatment of gastric antral vascular ectasia, as reflected in some studies.

Gender Differences in Acute Coronary Syndrome

Acute coronary syndrome (ACS) is common in women, yet we have less sex-specific data in women than in men as a result of lower enrollment in clinical trials and low rates of sex-specific reporting. Women are generally older with more comorbidities when diagnosed with ACS. Women with ACS are less likely than men to be referred for invasive evaluation and procedures and are more likely to have normal coronary arteries when they are referred for coronary angiography. For reasons that are not well understood, women have higher rates of bleeding complications compared with men. This higher bleeding rate is consistently seen in many trials. There are 3 major randomized, controlled trials that compared early invasive therapy with conservative strategy for ACS. Two of these trials found higher rates of myocardial infarction (MI) and death at 1 year in women treated with early invasive strategy, whereas the third trial found a reduction in the composite end point of rehospitalization, MI, and death at 180 days in women treated with early invasive strategy. Sex differences have also been seen in glycoprotein (GP) IIb/IIIa use in women with an increase in death and MI noted for GP use in women with ACS. Continued and increased numbers of women in clinical studies of ACS as well as increased rates of sex-specific reporting will allow us to offer optimal quality care for women and men with ACS.

Rituximab treatment of mild haemophilia A with inhibitors: a proposed treatment protocol

Inhibitors are an uncommon complication of mild haemophilia A but represent a severe disease, typically with high titre inhibitors and an associated high rate of bleeding. We present data from three patients with MHAI who were successfully treated with Rituximab alone and unequivocally prove that such inhibitors respond to this agent. A treatment protocol is suggested.

Asymptomatic Liver Mass

Asymptomatic Liver Mass

Correlates of Bleeding Events Among Moderate- to High-Risk Patients Undergoing Percutaneous Coronary Intervention and Treated With Eptifibatide: Observations From the PROTECT–TIMI-30 Trial

Correlates of Bleeding Events Among Moderate- to High-Risk Patients Undergoing Percutaneous Coronary Intervention and Treated With Eptifibatide: Observations From PROTECT–TIMI-30 Trial Ajay J. Kirtane, Gregory Piazza, Sabina A. Murphy, Daniela Budiu, David A. Morrow, David J. Cohen, Eric Peterson, Nasser Lakkis, Howard C. Herrmann, Theresa M. Palabrica, C. Michael Gibson, for the TIMI Study Group Among non–ST-segment elevation acute coronary syndrome percutaneous coronary intervention patients treated with eptifibatide, increased age was the only independent correlate of bleeding events. Although creatinine clearance (CrCl) was also associated with bleeding, that appeared to be related to the incorporation of age in the estimate of CrCl; reliance on serum creatinine alone as an estimate of renal function may yield inadequate dose reductions of eptifibatide. We aimed to identify correlates of Thrombolysis In Mycocardial Infarction (TIMI) major/minor bleeding among eptifibatide-treated patients undergoing percutaneous coronary intervention (PCI). Evaluation of bleeding predictors among patients treated with glycoprotein IIb/IIIa receptor inhibition might aid in the identification of targets to reduce bleeding risk. Data were analyzed from 567 moderate- to high-risk PCI patients with non–ST-segment elevation acute coronary syndrome (NSTEACS) treated with eptifibatide/reduced-dose unfractionated heparin or eptifibatide/reduced-dose enoxaparin enrolled in the Randomized Trial to Evaluate the Relative Protection Against Post-PCI Microvascular Dysfunction and Post-PCI Ischemia Among Anti-Platelet and Anti-Thrombotic Agents–Thrombolysis In Myocardial Infarction-30 (PROTECT–TIMI-30). The incidence of significant bleeding was 3.2% with a median time to event of 7.0 h after the first eptifibatide bolus. Increased age was the only independent correlate of bleeding events. Among patients with reduced creatinine clearance (CrCl), lack of adjustment of the maintenance infusion for CrCl ≤50 ml/min occurred frequently (15 of 33 patients, or 45%) and was associated with a high rate of bleeding (20%). The association of CrCl with bleeding appeared to be largely mediated by the incorporation of age in the estimation of CrCl. Patient gender, Cr, weight, and the peak activated clotting time were not associated with bleeding. Among NSTEACS PCI patients treated with eptifibatide, increased age was a significant correlate of bleeding events and appeared to explain the association between low CrCl and bleeding. The more widespread use of CrCl or other estimates of renal function over Cr may lead to more appropriate dose adjustments of eptifibatide.

Comparison of Proton Pump Inhibitor with H2 Receptor Antagonist for Prevention of Bleeding from Ulcer After Endoscopic Submucosal Dissection for Early Gastric Cancers: A Non-Blind Randomized Controlled Trial

Background: Proton pump inhibitor (PPI) and H2 receptor antagonist (H2RA) have similar effect on prevention of bleeding after endoscopic mucosal resection (EMR) for early gastric cancer (EGC) by conventional strip biopsy method. Introduction of wide spread EMR by endoscopic submucosal dissection (ESD) technique caused higher rate of bleeding after procedure than the conventional methods in our center. Objective: To evaluate preventive effects of PPI and H2RA on bleeding from ulcer after EMR by ESD. Design: A non-blind randomized controlled trial. Setting: Endoscopy unit at a cancer center. Patients: A total of 105 patients (84 men and 21 women, mean age 67 years old) with EGC treated by ESD technique between January and November 2005. Median (range) tumor size was 15 (5-105) mm. Patients having administration of anticoagulant and severe organ failure were excluded. Written informed consent was obtainted from all patients and the study protocol was approved by the institutional review board. Interventions: Patients were randomized to two groups; labeprazole 40 mg p.o. bid (PPI group) from one day before procedure, and cimetidine 800 mg div two days followed by cimetidine 800 mg p.o. bid (H2RA group). Treatments were continued for 8 weeks. Main outcome measurements: Bleeding that was defined as hematoemesis and melena required endoscopic hemostasis, and decreased Hb of less than 2 mg/dl. Results: Significant differences were not available in age, sex, history of peptic ulcer, status of Helicobacter pylori, mean tumor size, and location of the tumor between the groups. Bleeding rate of the PPI group (1.8%; 1/55) was significantly less than that in the H2RA group (12%; 6/50, p = 0.043). Late perforation was occured in two patients in the H2RA group. Limitations: Non-blind design and a relatively small number of subjects. Conclusion: PPI inhibits bleeding from ulcer and the adverse effect after ESD for EGC.

Yield of Capsule Endoscopy Includes Significant Gastric Findings, and Is Unaffected By Antiplatelet Or Anticoagulation Agents

Background: Capsule endoscopy (CE) is considered the gold standard diagnostic tool in evaluation of obscure bleeding of small bowel (SB) origin, but offers limited gastric imaging as well. All patients undergoing CE have had (-) upper & lower endoscopic studies, and many are on anticoagulation or antiplatelet therapy (Acptx). Aim: We wished to determine whether CE may find a significant number of missed gastric bleeding sources and studied whether the yield of CE differed in those on or off Acptx. Methods: Patients w/obscure GI bleeding referred for CE were retrospectively studied. All gastric and SB images were viewed by one of two experienced MDs. Hx, indications (Group:A-ongoing overt bleeding, B-previous overt bleeding, C-Fe def/heme +) and use of aspirin (ASA), Plavix and/or coumadin at time of capsule was obtained from EMR review. Evidence of bleeding (red blood-RB,coffee grounds-CG) and types of lesions in both gastric and SB images were identified and adjudicated for significance by the study PI. Results: 262 pts were referred for CE since 4/02; 175 had both bleeding indication and evaluable data. Indications were: group A: 21 pts(12%), B: 75(43%), and C: 79(45%). Gastric RB and CG was seen in 18/175 pts overall (10.3%, 10 RB, 8 CG). Associated gastric lesions were noted in the majority of these pts (10/18; 6-gastropathy, 3-erosion, 1 AVM). Of the pts with gastric blood, 13/18 (72%) had either no SB lesion or one small AVM, suggesting the gastric site was the primary cause of bleeding. Gastric blood was noted significantly more often in pts studied later in our series (3/23/04-11/05) than before (17% vs 5%, p < 0.05). There was no significant difference in the prevalence of gastric blood among pts on Acptx compared to those off (9.7% vs. 10.9%). Notably, SB lesions were found with similar frequency in those on or off any Acptx, or combinations of these agents (60.1% off, 56.6% on Acptx of any kind, 56% ASA alone, 57% combination). There was a trend toward higher frequency of RB or CG in the SB in those on Acptx, but this was not significant (12% in controls, 18% in Acptx group). Conclusions: The rate of SB findings on CE were unaffected by the presence of anticoagulation or antiplatelet therapy. We found a relatively high rate of gastric bleeding (10.3%) in our pts whether on anticoagulation or not. A significantly higher frequency of gastric blood was noted in studies done in the latter half of our series (16.1% vs. 4.5%). We expect that as CE is used earlier in the evaluation of obscure bleeding, lesions overlooked on routine endoscopy will increasingly be detected.

Secondary Stroke Prevention with Antiplatelet Drugs: Have We Reached the Ceiling?

Patients with transient ischemic attack (TIA) or ischemic stroke carry a risk of recurrent stroke of between 5% and 20% per year. In patients with TIA or ischemic stroke of non-cardiac origin, antiplatelet drugs are able to decrease the relative risk of stroke by 11-15% and the risk of stroke, myocardial infarction, and vascular death by 15-22%. Aspirin is the most widely used drug. It is affordable and effective. Low doses of 50-325 mg aspirin are as effective as high doses and cause less gastrointestinal side-effects. The combination of aspirin with slow-release dipyridamole is superior to aspirin alone for stroke prevention but not for the prevention of cardiac events. The risk of major bleeding complications is not increased with the combination, which suggests that dipyridamole might act in another way than as antiplatelet drug. Clopidogrel is not superior to aspirin in unselected stroke patients but is superior in patients at high risk of recurrence. The combination of aspirin plus clopidogrel is not more effective than clopidogrel alone, but carries a higher bleeding risk. The most effective antiplatelet drugs, the GP IIb/IIIa antagonists, are not superior to aspirin and carry a higher risk of bleeding. These results indicate that any antiplatelet therapy with a more potent drug than aspirin will only have a marginally higher efficacy, which might be offset by a higher bleeding rate. Therefore, selection of patients who might benefit from antiplatelet therapy other than aspirin is important.

To band or to block for primary prophylaxis against variceal bleeding?

To band or to block for primary prophylaxis against variceal bleeding?

未破裂脳動静脈奇形 小脳未破裂動静脈奇形の治療戦略

We report a retrospective analysis of 11 cases of non-ruptured cerebellar arteriovenous malformations (AVMs) among 294 cases of intracranial AVMs between 1981 and 2004. Eight of 11 cases were surgically treated. Seven patients had good outcomes (modified Rankin scale 0-2) and 1 patient was dead because of brainstem dysfunction after the removal of a giant cerebellar AVM. Surgical treatment is indicated for symptomatic cases, particularly for pediatric cases and cases associated with intracranial aneurysms because of the high bleeding rate and poor outcome after the hemorrhage. However, surgical treatment is contraindicated for arteriovenous malformations that extend to the cerebellar peduncle or brainstem, particularly for giant cerebellar AVM because of the high morbidity and mortality rates.

Hemorrhage following Coblation Tonsillectomy

We performed a prospective study to evaluate the incidence of post-tonsillectomy hemorrhage (PTH) in adults and children who underwent Coblation tonsillectomy (CTE) under general anesthesia. The data of 63 adults and children (mean age, 21.8 years) were analyzed. There were 7 episodes of considerable bleeding (11.1%) that required surgical treatment under general anesthesia in 6 patients, of whom 5 experienced secondary bleeding (>24 hours). Moreover, bleeding and massive swelling of the pharynx required surgical treatment and prolonged intubation (35 hours) in 1 patient. None of the patients received blood transfusions. There was no case with a lethal outcome. Less intense bleeding (clots; blood-tinged sputum) was observed in 17 patients (27%) who required readmission or prolonged inpatient observation, 1 of whom had previously undergone surgical treatment of PTH. However, these 17 patients had an uneventful clinical course. In total, 22 patients experienced minor or major forms of PTH (34.9%). At least in our hands, CTE dramatically increased the frequency of PTH. The high rate of secondary bleeding contrasts with our documented experience using conventional methods, ie, cold dissection and suture ligation, to achieve hemostasis (7.9% with CTE versus <0.8% with conventional methods). Therefore, at our institution, tonsillectomy with conventional instruments remains the method of choice.

Review article: low-dose aspirin, non-steroidal anti-inflammatory drugs and cyclo-oxygenase inhibitors - balancing risks and benefits

Summary In recent years, there has been a rapid increase in the number of patients using aspirin for the prevention of cardiovascular events and also other non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, for the treatment of arthritis. However, aspirin and non-steroidal anti-inflammatory drugs are associated with an increase in gastrointestinal risk. Recent studies have shown that cyclo-oxygenase-2 inhibitors, and possibly non-selective non-steroidal anti-inflammatory drugs, increase the cardiovascular risk. In patients taking aspirin, the ‘gold standard’ therapy to reduce gastrointestinal risk is concomitant therapy with a gastroprotective agent, such as a proton-pump inhibitor. Other gastroprotective agents, such as misoprostol, while equally effective may be associated with a higher proportion of adverse events. Helicobacter pylori infection has been shown to increase the risk of upper gastrointestinal bleeding associated with low-dose aspirin. Emerging data suggest that the eradication of H. pylori reduces the gastrointestinal risk of high-risk aspirin users. Other antiplatelet agents such as clopidogrel that were thought to be non-ulcerogenic have been widely used as alternatives to aspirin. However, recent studies have shown that clopidogrel induces an unacceptably high rate of ulcer bleeding in high-risk patients. When prescribing non-steroidal anti-inflammatory drugs therapy, treatment needs to be individualized according to the patients’ gastrointestinal and cardiovascular risk factors.

Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: an evidence‐based review

The literature was systematically reviewed to determine whether a prolonged prothrombin time or elevated international normalized ratio predicts bleeding during invasive diagnostic procedures. MEDLINE and CENTRAL were searched through August 2004, with no language restriction, and reference lists were reviewed. For inclusion, articles must have reported on bleeding in more than five patients with abnormal test results undergoing diagnostic procedures. One trial and 24 observational studies were included. In 2 studies of bronchoscopy, the bleeding rates were similar among those with normal and abnormal tests, with wide confidence intervals (CIs) around the risk differences. During central vein cannulation (3 studies), bleeding rates among those with abnormal tests was unlikely to exceed 2.3 percent. The largest of 3 studies of arteriography found equivalent bleeding rates in patients with and without abnormal tests (risk difference, 0%; 95% CI, -3% to 2%). In the 3 studies of liver biopsy with plugging, bleeding rates were 0, 4, and 5 percent with the upper bounds of the CI as high as 17 percent. In the largest study of transjugular biopsy, the bleeding rate was 1.5 percent (95% CI, 0.3%-4%) in patients with abnormal tests. The highest bleeding rate in the 3 studies of percutaneous liver biopsy was 5.3 percent (95% CI, 1%-13%), similar to the rate in patients with normal test results. There is insufficient evidence to conclude that abnormal test results predict bleeding. Randomized controlled trials should be performed to provide stronger evidence for clinical decision making regarding preprocedure transfusion.

Increased Incidence of Major Bleeding in Children Receiving Unfractionated Heparin for Clinical Management: A Prospective Cohort Study.

BACKGROUND: Unfractionated heparin (UFH) is one of the most frequently prescribed drugs in paediatric tertiary care centres and is used in a diverse group of disorders including cardiopulmonary bypass, extra corporeal membrane oxygenation, dialyses and maintenance of both venous and arterial catheter patency. Dosing of UFH in children is extrapolated from adults and is assessed by either a chromogenic Anti-Xa assay or a clot-based activated partial thromboplastin time (aPTT). The overall objective of the study was to assess safety of current standard of practice in the use of therapeutic UFH in children.Objective #1: The primary objective was to determine the incidence of bleeding and the incidence of recurrent thrombosis in children receiving UFH.Objective #2: To assess the monitoring UFH by assessing the relationship of the aPTT and Anti-Xa heparin levels to heparin dose.STUDY DESIGN: A prospective cohort study in nonselected children in a intensive care setting. The primary outcomes were major bleeding events and recurrent thrombosis. The secondary outcomes were assessing the APTT and Anti-Xa levels. Inclusion Criteria: Patients 〉 36 weeks gestation and 〈18 years of age requiring therapeutic doses of UFH. Exclusion Criteria: patients who received UFH for less than 1 day. Major bleeding was defined aprior as any of the following: CNS bleeding, retroperitoneal bleeding, and/or bleeding that results in stopping UFH infusion.RESULTS: Patient Population 39 patients were enrolled, 22 (56%) male, 32 (82%) < 1 year of age and 90% of which where cardiac patients. Major Bleeding events: 11/39 patients had a major bleeding event 28.2% (95% CI 15.0–44.9%). No patient had recurrent thrombosis. Relationship of aPPT and Anti-Xa to heparin dose; A total of 188 paired aPTTs and anti-Xa levels were performed. There was little correlation between aPTT and anti-Xa levels (r2=0.205) and APTT and UFH dose (r2=0.054). There was no relationship between anti-Xa levels and UFH dose (r2=0.0089). (Figure 1 and 2) [Display omitted] CONCLUSIONS:. There is an unacceptably high rate of bleeding in children receiving UFH for clinical care. There is little or no relationship of aPPT and Anti-Xa to heparin dose. Clinical trials are needed to assess the appropriate use of UFH therapy in children.

Transcultural expression of subcortical vascular disease

Background Many transcultural issues pertaining to subcortical vascular disease remain unanswered, and there is a relative paucity of research on stroke and dementia in non-Western societies. Objective To describe variations in the epidemiology of stroke and dementia, the recognition of dementia as an entity across cultures, the cultural specificity of screening tools and assessment instruments, and cultural influences on the management of stroke and dementia. Results Several studies have pointed out differences in the subtypes and outcomes from stroke across different world regions. Notably, non-Western populations may have a higher rate of hemorrhage, whilst in ischemic stroke subcortical vascular disease is predominant. A low prevalence of dementia has been demonstrated in many studies of non-Western populations. Factors proposed to account for this include protective family attitudes, a lower frequency of ApoE4 and the high mortality of non-Western dementia subjects, which may mask a high age-specific incidence rate. Other medical factors such as training, diagnostic skills, the availability of investigations and healthcare provision may also play a role, as would patient specific cultural attitudes towards ageing and mental health, together with differences in language, social customs and literacy. It has been suggested that there is a major difference between Western and Asian nations in the ratio of vascular dementia to Alzheimer disease. However, few epidemiological field studies have utilized neuroimaging and the reported rates for particular diagnoses should be interpreted cautiously. A recent population study in Japan, which utilized screening by neuropsychologists and CT scanning, showed that vascular dementia accounted for nearly half the cases of dementia. Subcortical vascular disease accounts for the majority of patients with vascular dementia (VaD). Conclusions With the rapid demographic changes taking place in non-Western countries, non-communicable diseases such as dementia and stroke will increasingly come to dominate disease burden. More studies are required to prevent and treat these diseases.

Relationship between activated clotting time and ischemic or hemorrhagic complications: analysis of 4 recent randomized clinical trials of percutaneous coronary intervention.

Unfractionated heparin (UFH) is the most widely used antithrombin during percutaneous coronary intervention (PCI). Despite significant pharmacological and mechanical advancements in PCI, uncertainty remains about the optimal activated clotting time (ACT) for prevention of ischemic or hemorrhagic complications. We analyzed the outcome of all UFH-treated patients enrolled in 4 large, contemporary PCI trials with independent adjudication of ischemic and bleeding events. Of 9974 eligible patients, maximum ACT was available in 8369 (84%). The median ACT was 297 seconds (interquartile range 256 to 348 seconds). The incidence of death, myocardial infarction, or revascularization at 48 hours, by ACT quartile, was 6.2%, 6.8%, 6.0%, and 5.7%, respectively (P=0.40 for trend). Covariate-adjusted rate of ischemic complications was not correlated with maximal procedural ACT (continuous value, P=0.29). Higher doses of UFH (>5000 U, or up to 90 U/kg) were independently associated with higher rates of events. The incidence of major or minor bleeding at 48 hours, by ACT quartile, was 2.9%, 3.5%, 3.8%, and 4.0%, respectively (P=0.04 for trend). In a multivariable logistic model with a spline transformation for ACT, there was a linear increase in risk of bleeding as the ACT approached 365 seconds (P=0.01), which leveled off beyond that value. Increasing UFH weight-indexed dose was independently associated with higher bleeding rates (OR 1.04 [1.02 to 1.07] for each 10 U/kg, P=0.001). In patients undergoing PCI with frequent stent and potent platelet inhibition use, ACT does not correlate with ischemic complications and has a modest association with bleeding complications, driven mainly by minor bleeding. Lower values do not appear to compromise efficacy while increasing safety.

Coblation tonsillectomy: Scaring rates of postoperative bleeding

Objectives: A prospective study was undertaken to evaluate the bleeding tendency during tonsillectomy and afterward in adults and children with a history of chronic or recurrent tonsillitis. Methods: A total of 60 patients (33 female, 27 male) were scheduled for tonsillectomy under general anesthesia. The youngest was 44 months, the oldest 69 years of age (mean, 21.8; median, 18; STD, 15.6 years). Results: All tonsillectomies were performed under microscopic control. The settings of the technical devices were used as uniformly recommended. Due to the possibility of meticulous dissection, virtually no bleeding occurred during dissection. There were 6 episodes of considerable bleeding requiring surgical treatment under general anesthesia in 5 patients 4 of whom experienced secondary bleeding (>24 hours). No patient required blood transfusions. There was no case with lethal outcome. Readmission was indicated in 13 patients with posttonsillectomy hemorrhage of lesser intensity with uneventful clinical course. Conclusions: In our hands, coblation-tonsillectomy dramatically increased the rate of posttonsillectomy bleeding. The high rate of secondary bleeding contrasts sharply to our well-studied clinical experience with the conventional method (cold dissection) and the promising results recently presented in the literature. Due to the paucity of clinical reports and our scaring experience concerning coblation-tonsillectomy, we currently cannot recommend the use of this instrument. Moreover, the cost-benefit ratio dramatically suffers from the fact of high complication rates and cost for the single-use instrument (about 135 US$).

Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids.

Rubber band ligation therapy for symptomatic hemorrhoidal disease has been used for many years and is a well-accepted treatment modality, but information on long-term outcome is limited. Our goals were to determine safety and long-term efficacy of this treatment. A retrospective chart review of patients undergoing rubber band ligatures for symptomatic internal hemorrhoids in a single practice was conducted. Information on presenting symptoms, number of bands applied, response to therapy, complications encountered, length of follow-up, interval to recurrent symptoms when applicable, and subsequent therapy were documented. Supplemental information was obtained from telephone follow-up. Outcome was categorized as success or failure, in which success was defined as: permanent relief of symptoms for follow-up period; marked improvement in symptomatology with rare manifestation of bleeding (< or = 1/month); symptom relief for a limited period of time (> or = 100 days), and failure was defined as: modest improvement (decreased but not relief of symptoms); or no improvement in symptoms. A total of 805 patients underwent 2,114 rubber band ligatures. Most common presenting symptoms were bleeding in 731 patients (90.8 percent) and prolapsing in 382 patients (47.5 percent). The median number of bands placed was two (range, 1-17). The median time between bandings was 4.7 (range, 1.1-35.6) weeks. Median follow-up time was 1,204 (range, 14-9,571) days. Excluding 104 patients lost to follow-up (never returned after initial treatment), success was obtained in 70.5 percent (494/701) and failure in 29.5 percent (207/701) of patients. Success rates were similar for all degrees of hemorrhoids. Hemorrhoidal disease requiring the placement of four or more bands was associated with a trend in higher failure rates and greater need for subsequent hemorrhoidectomy. Complications per treatment series included bleeding (2.8 percent), thrombosed external hemorrhoids (1.5 percent), and bacteremia (0.09 percent). Higher bleeding rates were encountered with the use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin. Time to recurrence was less with subsequent treatment courses. Treatment of recurrent symptoms with rubber band ligation resulted in success rates of 73.6, 61.4, and 65 percent for first, second, and third recurrences respectively. This resulted in a cumulative success rate of 80.2 percent for this method of treatment. Rubber band ligatures are safe and effective therapy for symptomatic internal hemorrhoids. It can be used to treat all degrees of hemorrhoids with similar effectiveness. The likelihood of success is lower if more than four bands are needed to eliminate symptoms. The use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin is associated with higher bleeding rates. Rubber band ligatures for recurrence of symptoms is effective; however, time to recurrence is less with subsequent treatments.

Bleeding events with abciximab in acute coronary syndromes without early revascularization: an analysis of GUSTO IV–ACS

Background The glycoprotein IIb/IIIa receptor antagonist abciximab reduces the risk of thrombotic complications with percutaneous coronary intervention, but also has been associated with higher bleeding rates. Methods In the Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes (GUSTO IV–ACS) trial, abciximab (either a 24-hour or 48-hour infusion) was compared with placebo in 7800 patients with an acute coronary syndrome. During study drug administration, 2% of the patients underwent a revascularization procedure. Results In 1507 patients (19.3%), bleeding according to the Thrombolysis in Myocardial Infarction (TIMI) classification was observed while they were hospitalized or within 7 days. Ninety-eight patients (1.2%) had a major bleed, including 8 with intracranial hemorrhages. In 215 patients (2.8%), a minor bleed was reported, and in 1194 patients (15.3%), an insignificant bleed was reported. Bleeding was more frequent in patients receiving a 48-hour infusion of abciximab. Spontaneous bleeding was seen in 911 patients (11.7%). The other 596 patients had a bleeding event in conjunction with a procedure. The most significant predictors for bleeding with multivariable analysis were: use of low-molecular weight heparin, duration of abciximab infusion, region of hospitalization, performance of coronary artery bypass grafting or percutaneous coronary intervention (PCI), advanced age, and female sex. For major bleeding, the predictors were performance of coronary artery bypass grafting or PCI, long duration of abciximab administration, and advanced age. Conclusion Treatment with abciximab in patients with non-ST–elevation acute coronary syndromes is safe because major bleeding and stroke are rare, and most events are clinically manageable or have few clinical consequences. Guidelines for use of abciximab in combination with other antithrombotic agents developed for PCI should also be respected in acute coronary syndromes. Specific dosing guidelines for combination with low-molecular weight heparin must be developed for patients who subsequently will undergo a PCI.

Addition of heparin to contrast media is associated with increased bleeding and peripheral vascular complications during percutaneous coronary intervention with bivalirudin and drug-eluting stents

Background Nonionic radiographic contrast media (CM) is reported to be thrombogenic while performing diagnostic or interventional procedures. To avoid thrombosis, heparin is often added to the CM. Bivalirudin, used to replace heparin during percutaneous coronary intervention (PCI), is reported to be associated with reduced bleeding complications. We aimed to evaluate the impact of adding heparin to the CM during PCI in patients (pts) who underwent sirolimus-eluting stent (SES) implantation when bivalirudin was utilized as the sole antithrombotic agent. Methods A total of 664 pts with 756 lesions underwent standard PCI with SES for various coronary artery lesions. Pts were treated with either bivalirudin only (the bivalirudin group; 0.75 mg/kg bolus and 1.75 mg/kg/h infusion, n=323 pts) or bivalirudin (same dose) plus low-dose heparin added to the CM (the heparin mix group; mean dose=2101.8±882.5 U, n=341 pts) during PCI. The periprocedural, in-hospital, and 30-day clinical outcomes were compared. Results Baseline clinical and angiographic parameters were similar between both groups. Periprocedural, in-hospital, and 1-month clinical outcomes, including thrombotic complications, were similar between the two groups. There was no difference in the periprocedural thrombosis rate between the groups. In the heparin mix group, the overall incidence of hematoma was significantly higher (3.8% vs. 8.5%, P=.01), there was a trend toward higher rates of blood transfusion (2.6% vs. 6.6%, P=.06) and overall vascular complications (0.01% vs. 5.3%, P<.001), including pseudoaneurysm (PSA; 0.0% vs. 2.6%, P=.004), and pts who required surgical repair (0.3% vs. 1.8%, P=.07). Conclusions The routine addition of low-dose heparin to CM during contemporary PCI does not add any protection value and is associated with higher rates of bleeding and vascular complications.