Hospital Admissions For Bleeding Research Articles

Temporal trends in major bleeding after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction from 2003 to 2017: the Western Denmark Heart Registry

Abstract Background Management of patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) has changed during the last two decades. Introduction of more potent platelet inhibitors may carry an increased risk of bleeding complications, while other therapeutic options, such as use of radial artery access and proton pump inhibitors may reduce bleeding risk. The combined impact of these treatment changes on bleeding risk in patients with STEMI remains unknown. Purpose To examine temporal trends in 1-year risk of major bleeding after STEMI treated with primary PCI from 2003 to 2017. Methods We used the Western Denmark Heart Registry to identify first-time PCI-treated patients undergoing primary PCI for STEMI from 2003 to 2017. Patients were divided into 4 calendar periods based on the time of STEMI. The main outcome was 1-year risk of major bleeding defined as a hospital admission for bleeding using a validated definition with high accuracy. Additionally, the 1-year risk of major bleeding in STEMI patients was compared with the risk in an age- and sex-matched general population cohort without prior coronary artery disease. Results From 2003 to 2017, we identified 18,540 patients treated with primary PCI for STEMI (median age 64 years, 75% men)and 92,700 age- and sex-matched individuals. The 1-year risk of major bleeding after STEMI was similar across the different time periods; 4.1% in 2003-2006, 3.8% in 2007-2010, 3.8% in 2011-2014, and 4.5% in 2015-2017. The adjusted HR for bleeding in STEMI patients was 1.03 (95% CI 0.83-1.26) when comparing the latest period with the earliest period. The age- and sex-matched general population exhibited a 1-year risk of major bleeding of around 1% in all time periods (Figure 1). Conclusions Despite changes in management, the 1-year risk of major bleeding remained stable around 4% after primary PCI-treated STEMI from 2003 to 2017. This risk was approximately 4 times higher than the bleeding risk observed in an age- and sex-matched general population.

Prevalence and impact of frailty in elderly patients with chronic and acute coronary syndrome referred for coronary angiography

Abstract Background The population is getting older worldwide, therefore specific knowledge regarding elderly with cardiovascular disease (CVD) is increasingly needed. Frailty has previously been suggested as a valuable marker for outcome prediction in older CVD patients. Whether the importance of frailty is similar in patients with chronic coronary syndrome (CCS) and acute coronary syndrome (ACS) is not well described. Purpose To compare outcome among frail patients ≥70 years old refereed for coronary angiography (CAG) due to CCS and ACS. Methods Patients ≥70 years old, referred for CAG due to CCS or ACS at our department between 2020-2021, were included in the study and followed for one year. Frailty was evaluated with the Clinical Frailty Scale (CFS) by trained nurses as a part of everyday practice at the cardiology ward. Patients were pooled according to their CFS into a frail/vulnerable (CFS ≥4) and a robust group (CFS 1-3). Study endpoints were all-cause mortality and new hospital admissions for bleeding, myocardial infarction (MI), unplanned revascularisation, or stroke. Results During the study period, a total of 678 patients ≥70 years underwent CAG due to CCS (n=223) or ACS (n=455), had their level of frailty evaluated and completed one-year follow-up. The prevalence of frailty/vulnerability was higher among patients with CCS as compared to patients with ACS (CCS: 43.0% vs. ACS: 32.2%, p=0.009). Frail/vulnerable patients with CCS were younger (CCS: 76.6 (4.7) years vs. ACS: 79.6 (5.7) years, p<0.001), and had a higher body mass index (CCS: 28.5 (4.6) kg/m2 vs. ACS: 27.1 (5.1) kg/m2). Furthermore, frail/vulnerable patients with CCS had more often a history of coronary artery disease, heart failure and hypercholesteremia. PCI was more frequently performed in frail/vulnerable patients with ACS compared to CCS (CCS 40.6% vs. ACS 54.6%, p=0.043) and the use of coronary artery bypass was very low (CCS 6.2% vs. ACS 4.1%, p=0.637), table 1. At one-year follow-up, all-cause mortality was lower among frail/vulnerable patients with CCS (CCS: 4.2% vs. ACS: 23.1%, p<0.001). There was no difference in the number of new hospital admissions for bleeding, MI, unplanned revascularisation, or stroke (CCS: 39.4% vs ACS: 42.0%, p=0.79). In Kaplan Meier analysis, cumulated all-cause mortality was lower among both frail/vulnerable and robust patients with CCS as well as robust patients with ACS, as compared to frail/vulnerable patients with ACS (log-rank p<0.001), figure 1. There was no difference in all-cause mortality among robust patients with CCS, as compared to robust patients with ACS (Hazard ratio (HR) 0.37, 95% confidence interval (CI) 0.11-1.27, p=0.11). Conclusion Among patients ≥70 years old referred for CAG, frailty was associated with a higher all-cause mortality in patients with ACS, but not in patients with CCS. Furthermore, there were no differences in one-year all-cause mortality between robust patients with CCS and ACS.Table 1Figure 1

Evaluation of a pharmacist-led drive-up anticoagulation clinic during the coronavirus 2019 pandemic

BackgroundThe University of Kentucky HealthCare Anticoagulation Clinic at the Gill Heart and Vascular Institute in Lexington, Kentucky, designed and implemented a drive-up clinic for warfarin management with the goal to minimize person-to-person exposure during the coronavirus disease 2019 (COVID-19) pandemic. ObjectiveThe purpose of this study was to evaluate the effect on warfarin management in a pharmacist-led anticoagulation service when transitioned from an in-person clinic to a drive-up clinic during the COVID-19 pandemic. MethodsThis is a retrospective observational cohort study of 68 patients seen in the University of Kentucky HealthCare Anticoagulation Clinic on warfarin therapy for any indication. Patients were included if they had scheduled visits at least 3 times in the period 6 months before, during, and after the initiation of the drive-up clinic. The primary outcome is the difference in time in therapeutic range (TTR) before and during the drive-up clinic. ResultsThe difference between the mean TTR in period 1 (69.1% ± 23.2%) and period 2 (69.6% ± 19.2%) was not statistically significant (P = 0.882). The mean TTR in period 3 (70.5% ± 20.8%) did not differ in statistical significance from either period 1 (P = 0.688) or period 2 (P = 0.746). Safety outcomes including reported bleeding events and emergency department visits or hospital admissions for bleeding or thrombotic events were consistently low across each period. ConclusionThe results of this study illustrate that a drive-up clinic for warfarin management may be a reasonable alternative approach to providing care for outpatient anticoagulant management and may support nontraditional clinic models for long-term management of anticoagulation and other chronic disease states.

A randomized controlled trial of methylergonovine prophylaxis after dilation and evacuation abortion

ObjectiveTo evaluate the efficacy of intramuscular methylergonovine maleate as prophylaxis against excessive bleeding when given after dilation and evacuation (D&E) at 20–24 weeks. Study designWe performed a randomized, double-blinded, placebo-controlled trial in patients without excessive bleeding requiring intervention after D&E completion. We administered study treatment within one minute of the end of the procedure. We primarily compared outcomes using a composite of indicators of excessive post-procedure blood loss (post-procedure measured blood loss exceeding 125 mL, uterine massage or compression for at least two minutes, administration of additional uterotonic medication, intrauterine balloon tamponade, uterine re-aspiration, blood transfusion, uterine artery embolization, hospital admission for bleeding, or major surgery). Secondary outcomes included individual indicator occurrences, satisfaction, and side effects. ResultsFrom March 3, 2015 to March 31, 2017, we randomized 284 participants (n = 140 methylergonovine, n = 144 placebo), five before we registered the trial with clinicaltrials.gov. Baseline characteristics were similar between groups. The composite outcome occurred in 78 (56%) methylergonovine and 75 (52%) placebo participants (p = 0.5). Methylergonovine recipients required more intrauterine balloon use (n = 20 [14%]) versus placebo (n = 10 [7%]), p = 0.04. We also observed a non-significant trend towards more uterotonic administration (n = 56 [40%] versus n = 43 [30%], p = 0.07) and hospital admissions for bleeding (n = 4 [3%] versus n = 0, p = 0.06) in the methylergonovine group compared to placebo. ConclusionWe observed no improvement in the composite outcome for excessive bleeding with prophylactic post-procedure methylergonovine. In addition, individual excessive bleeding outcomes occurred more frequently in the methylergonovine group, potentially indicating harm with its prophylactic use after D&E. ImplicationsWhen administered prophylactically immediately after dilation and evacuation abortion at 20–24 weeks, methylergonovine increases uterine bleeding. Given the lack of data for effectiveness as a prophylactic agent and our findings indicating harm, we do not recommend its use for post-operative prophylaxis.