Independent Risk Factor For Bleeding Research Articles

Taking antithrombic therapy during emergency laparoscopic cholecystectomy for acute cholecystitis does not affect the postoperative outcomes: a propensity score matched study

BackgroundContinuing antithrombic therapy (ATT) during surgery increases the risk of bleeding. However, it is difficult to discontinue the ATT in emergency surgery. Therefore, safety of emergency laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) is still unclear. We aimed to clarify the affect of ATT during emergency LC for AC.MethodsPatients with AC were classified into ATT group (n = 30) and non-ATT group (n = 120). Postoperative outcomes were compared after propensity score matching (n = 22).ResultsHigher level of c-reactive protein level and shorter activated partial thromboplastin time (APTT) was observed in ATT group than in non-ATT group after matching. No significant difference was found between other patient characteristics and perioperative results. Blood loss over 100 mL was observed in 8 patients. Multivariate analyze showed that APTT was an independent risk factor for bleeding over 100 mL (P = 0.039), while ACT and APT was not.ConclusionsTaking ATT does not affect the blood loss or complications during emergency LC for AC. Controlling intraoperative bleeding is essential for a safe postoperative outcome.

Genetic Factors of Renin-Angiotensin System Associated with Major Bleeding for Patients Treated with Direct Oral Anticoagulants.

The purpose of this study was to identify the renin–angiotensin system (RAS)-related genetic factors associated with bleeding and develop the bleeding risk scoring system in patients receiving direct oral anticoagulants (DOACs). This study was a retrospective analysis of prospectively collected samples from June 2018 to May 2020. To investigate the associations between RAS-related genetic factors and major bleeding, we selected 16 single nucleotide polymorphisms (SNPs) from five genes (namely, AGT, REN, ACE, AGTR1, and AGTR2). Multivariable logistic regression analysis was employed to investigate the independent risk factors for bleeding and to develop a risk scoring system. A total of 172 patients were included in the analysis, including 33 major bleeding cases. Both old age (≥65 years) and moderate to severe renal impairment (CrCl < 50 mL/min) increased the risk of bleeding in the multivariable analysis. Among RAS-related polymorphisms, patients carrying TT genotype of rs5050 and A allele of rs4353 experienced a 3.6-fold (95% CI: 1.4–9.3) and 3.1-fold (95% CI: 1.1–9.3) increase in bleeding, respectively. The bleeding risk increased exponentially with a higher score; the risks were 0%, 2.8%, 16.9%, 32.7%, and 75% in patients with 0, 1, 2, 3, and 4 points, respectively. Although this study is limited to a retrospective study design, this is the first study to suggest RAS-related genetic markers and risk scoring systems, including both clinical and genetic factors, for major bleeding in patients receiving DOAC treatment.

Clinical Features and Risk Factors Analysis for Hemorrhage in Adults on ECMO.

Background: The use of extracorporeal membrane oxygenation (ECMO) to support critically ill patients with cardiorespiratory dysfunction has increased over the last decades. However, hemorrhagic complications occur frequently during ECMO support, and this has a significant impact on morbidity and mortality. Thus, this study aimed to identify the risk factors for hemorrhage in patients receiving ECMO.Methods: Our retrospective study included 60 patients, who were admitted to the Taihe Hospital in Shiyan City, Hubei Province, China from February 2017 to October 2020. About 18 patients developed hemorrhagic complications, and 42 patients did not demonstrate such complications. Data regarding patient demography, laboratory tests, and clinical manifestations prior to ECMO were collected to analyze their clinical features. Univariable and multivariable logistic analyses were used to explore the risk factors for hemorrhage in adults on ECMO. The receiver operating characteristic (ROC) curve was used to evaluate the predictive value of the binary logistic model. The amount of blood transfusions was compared between the two groups, and the activated partial thromboplastin time (APTT), platelet count, and hemoglobin level before the initiation of ECMO.Results: Logistic analysis showed that a longer duration of ECMO support, higher APTT, and lower platelet count prior to ECMO were independent risk factors for hemorrhage in adults on ECMO. In addition, we found that the cannula site was the most common bleeding site. Most bleeding events occurred within the first 3 days of ECMO therapy. After the ECMO initiation, APTT was prolonged while the platelet count and hemoglobin levels were decreased. The amount of blood transfusion was significantly higher in the hemorrhage group than in the non-hemorrhage group.Conclusions: Clinicians should evaluate the risk of hemorrhage based on the coagulation function of patients, underlying disease, and the duration of ECMO support. In the first 3 days during ECMO support, special attention should be given to the cannula site, mucosal, and dermal regions, and digestive tract to detect any signs of hemorrhage. Moreover, increasing the platelet count transfusion threshold and accurately determining the amount of blood transfusion required may prevent bleeding events.

Ticagrelor or clopidogrel after acute coronary syndrome in the elderly: a propensity score matching analysis from 16 653 patients included in two large multinational registries

Abstract Background Higher risk of bleeding with ticagrelor over clopidogrel in elderly patients with acute coronary syndrome (ACS) has been suggested. Purpose We assessed the incidence of major bleeding (MB), reinfarction (REAMI), and all-cause death in elderly patients to evaluate the safety and efficacy of ticagrelor versus clopidogrel in a population at high risk of bleeding and ischemia treated with percutaneous coronary intervention (PCI). Methods RENAMI and BleeMACS, real-world registries of patients with ACS who underwent PCI and received dual antiplatelet therapy, were merged. The pooled cohort was divided into two groups, clopidogrel versus ticagrelor and propensity score matching (PSM) analysis performed. Statistical analysis considered two age groups (&amp;lt;75 versus ≥75 years). Endpoints were BARC 3–5 MB, REAMI and all-cause death at 1 year. Independent risk factors of MB were identified. Results The study included 16,653 patients (13,153 &amp;lt;75 and 3,500 ≥75 years). Ticagrelor was underused in elderly patients (16.3% versus 20.8%, P&amp;lt;0.001). Using PSM, two treatment groups of 1,566 patients were included in the final analysis. Ticagrelor appeared to prevent REAMI (hazard ratio [HR], 0.31; 95% confidence interval [CI], 0.2–0.6; P&amp;lt;0.001) and all-cause death (HR, 0.60; 95% CI, 0.4–0.9; P=0.026) irrespective of age. In patients ≥75 years, ticagrelor increased the incidence of MB compared with clopidogrel (HR, 1.49; 95% CI, 0.70–3.0; P=0.257) without statistical significance; ticagrelor was found to significantly reduce all-cause death (HR, 0.32; 95% CI, 0.1–0.8; P=0.012) and REAMI (HR, 0.25; 95% CI, 0.1–1.1, P=0.072) without statistical significance. Multiple Cox regression revealed that age (HR, 1.03; 95% CI, 1.02–1.05; P&amp;lt;0.001) was an independent risk factor for bleeding, whereas hemoglobin level was inversely proportional to bleeding (HR, 0.80; 95% CI, 0.72–0.88; P&amp;lt;0.001). Conclusions Ticagrelor did not significantly increase MB compared with clopidogrel in elderly patients hospitalized for ACS and treated with PCI, significantly improving 1-year survival. Further studies on elderly patients are required. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Astra Zeneca

Age-adjusted risk factors are independently associated with an increased risk of major bleeding during the two-year follow-up of the ETNA-AF-Europe registry

Abstract Background Non-vitamin K antagonist oral anticoagulants (NOACs) are a preferred treatment option over warfarin for anticoagulation in patients with atrial fibrillation (AF). Management decisions for thromboprophylaxis in AF need to balance the risk of stroke against the risk of bleeding. Various patient characteristics have been identified as independent risk factors for bleeding. A substantial number of bleeding events might be prevented if independent predictors of bleeding were identified. Purpose The present analysis aims at assessing age-adjusted risk predictors of major bleeding during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry. Methods ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and major bleeding after adjusting for age, given that age is a well-known, strong predictor of anticoagulation-related bleeding in patients with AF. Results Overall, 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. Mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively. 438 (3.3%) patients had a history of bleeding events at baseline, of which 138 (1.0%) had a history of major bleeding event. Univariate analysis demonstrated that recalculated glomerular filtration rate (Cockcroft-Gault Equation) (GFR-CG) at baseline was the strongest age-adjusted predictor of major bleeding (Wald Chi-Square: 31.84; p&amp;lt;0.0001) (Figures 1 and 2), followed by history of major or clinically relevant non-major (CRNM) bleeding (24.08; p&amp;lt;0.0001), HAS-BLED score (21.10; p&amp;lt;0.0001), history of heart failure (derived) (16.59; p&amp;lt;0.0001), subjective frailty as assessed by physician (17.35; p=0.0002), history of major bleeding (14.14; p=0.0002), chronic obstructive pulmonary disease (COPD) (12.84; p=0.0003), CHA2DS2-VASc (12.14; p=0.0005), history of myocardial infarction (MI) (7.79; p=0.005), and left ventricular ejection fraction (LVEF) categorised by 40% (5.45; p=0.02). Conclusion Bleeding events on therapy with edoxaban can be predicted by quantifying kidney disease and capturing information on heart failure, frailty, prior bleeding, chronic obstructive lung disease and history of myocardial infarction. These data highlight the need for optimal management of anticoagulation therapy and close follow-up of patients with such risk profiles. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. GFR-CG as a predictor of major bleedingFigure 2. Predictors of major bleeding

Factors associated with symptomatic intracranial haemorrhage after intravenous thrombolysis in severe white matter lesions: a retrospective analysis

Background and purposeWhite matter lesions (WMLs) are thought to cause damage to the blood–brain barrier, thereby aggravating bleeding after intravenous thrombolysis. However, the risk factors for symptomatic cerebral haemorrhage after...

Evaluation of Risk Factors for Bleeding After Ultrasound-Guided Liver Biopsy.

PurposeThis study was performed to analyze the risk factors for hemorrhagic complications after ultrasound-guided liver biopsies.Patients and MethodsIn this retrospective study, we reviewed 1193 ultrasound-guided percutaneous liver biopsies performed in our hospital from January 2018 to December 2020. Relevant patient characteristics, indications for biopsy, laboratory findings, biopsy technique, hemorrhagic complications, and pathologic outcomes were collected.ResultsWe analyzed 834 procedures performed on 807 patients with complete data. The bleeding group comprised 45 patients with post-procedure bleeding, and non-bleeding group comprising the remaining 789 patients. Univariate analysis showed that age (p < 0.001), number of needle passes (p = 0.009), platelet count (p = 0.002), prothrombin time (p < 0.001), and international normalized ratio (p < 0.001) were associated with post-procedure bleeding. Multivariable regression analysis showed that age under 18 years (p < 0.001), low platelet count (p = 0.001), and increased needle passes (p = 0.025) were independent risk factors for bleeding complications.ConclusionSex and focal liver lesions did not affect the risk of post-procedure bleeding. The international normalized ratio and prothrombin time were associated with an increased incidence of bleeding; however, they had no predictive value. Age, number of needle passes, and platelet count were identified as reliable predictors of bleeding.

Risk of bleeding following double balloon enteroscopy in patients on continued antiplatelet and/or anticoagulation therapy.

Background and study aims Anticoagulation (AC) and antiplatelet (AP) therapy may increase the risk of gastrointestinal bleeding after double balloon enteroscopy (DBE); however, limited data are currently available regarding the incidence. The aim of this study was to assess the incidence and clinical characteristics of post-DBE bleeding in patients on AC and AP therapy. Patients and methods The medical records of patients who underwent DBE between 2009 and 2013 at Mayo Clinic, Florida, were retrospectively reviewed. Patients were divided into three groups: 1) continued AP therapy; 2) AC therapy; and 3) neither AP nor AC at the time of DBE. Follow-up data were collected at 60 days and 1 year. Results A total of 683 patients were identified; 43 on AC, 183 on AP and 457 not on AP or AC therapy. The most common indication for DBE was obscure gastrointestinal bleeding in the groups on and not on AP (85.3 % vs 70.9 %, P < 0.0001). There was no statistical difference in post-DBE bleeding rates in patients on AP vs not on AP at 60 days (11.5 % vs 7.5 %, P = 0.12) or 1 year (19.9 % vs 15.7 %, P = 0.23). Rates of bleeding in patients on AC were 11.6 % within 60 days and 22.5 % within 1 year. Multivariate analysis reflected American Society of Anesthesiologist > 3 and indication for DBE of GI bleeding were independent risk factors for post-DBE bleeding within 1 year. Conclusions Continued antiplatelet use at the time of DBE was not an independent risk factor for bleeding post-DBE at 60 days or 1 year of follow up.

Bleeding Risk Score in Patients with Crimean-Congo Hemorrhagic Fever

Bleeding is considered to be an indicator of poor prognosis in Crimean-Congo hemorrhagic fever (CCHF) disease. In the prehemorrhagic period, clinical signs are usually non-specific. The hemorrhagic period usually begins 3 to 5 days after the onset of the disease. The aim of this study was to build a risk score to predict bleeding status in CCHF patients with clinical and laboratory findings. This methodological study was carried out in one of the largest centers which is located in the east part of Turkey and CCHF-endemic region between April 2014-October 2019 with 450 CCHF patients' data. Risk score was created with univariate and multivariate logistic regression analyzes with the data of 80% of the patients, and the diagnostic power of the created score was determined by ROC analysis. The data of the remaining 20% were used as the verification data set and the created score was tested by ROC analysis. The patients had a mean age of 47.83 ± 17.46 years (median 48; min-max: 16-90 years) and 209 (59.7%) were male. Hemorrhage was detected in 93 patients (26.6%). Of the hemorrhagic patients, 83 (23.7%) had multiple hemorrhage sites. In univariate analyzes, time between the onset of symptom and admission to the hospital (≥4 days), aspartate aminotransferase (≥228 U/L), alanine aminotransferase (≥143.5 U/L), lactate dehydrogenase (≥641 U/L), creatine kinase (≥227 U/L), white blood cell count (≤1810 × 106/L), platelet count (≤38385 × 106/L), activated partial thromboplastin time (≥38.5 s) and fibrinogen value (≤227 mg/dl) were found to be an independent risk factor for bleeding. As a result of multivariate analysis, the time between the onset of symptoms and admission to the hospital, white blood cell count, platelet count, aspartate aminotransferase, creatine kinase and fibrinogen values were included in the risk scoring. The area under the curve of the generated score is 0.875; sensitivity was 80.6% and specificity was 80.5%. Platelet count responsible for hemostasis, affected in terms of number and function in CCHF disease, LDH, AST and aPTT values used as indicators of liver functions that are the target of the virus can be used with high diagnostic prediction for bleeding. However, the predictive power of the generated score on bleeding is higher than the effect of each variable alone. In addition, it can be easily calculated during patient follow-up and can guide the treatment process.

Ticagrelor or Clopidogrel After an Acute Coronary Syndrome in the Elderly: A Propensity Score Matching Analysis from 16,653 Patients Treated with PCI Included in Two Large Multinational Registries.

Higher risk of bleeding with ticagrelor over clopidogrel in elderly patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI) has been suggested. We assessed the incidence of major bleedings (MB), reinfarction (re-MI), and all-cause death to evaluate safety and efficacy of ticagrelor versus clopidogrel in such population. Real-world registries RENAMI and BleeMACS were merged. The pooled cohort was divided into two groups, clopidogrel versus ticagrelor. Statistical analysis considered patients <75 versus ≥75years old. Endpoints were BARC 3-5MB, re-MI, and all-cause death at 1-year follow-up. The study included 16,653 patients (13,153 < 75 and 3500 ≥ 75years). Ticagrelor was underused in elderly patients (16.3% versus 20.8%, P< 0.001). Using propensity score matching (PSM), two treatment groups of 1566 patients were included in the final analysis. Ticagrelor was able to prevent re-MI (hazard ratio [HR], 0.31; 95% confidence interval [CI], 0.2-0.6; P< 0.001) and all-cause death (HR, 0.60; 95% CI, 0.4-0.9; P= 0.026) irrespective of age. In patients ≥75years, ticagrelor reduced all-cause death (HR, 0.32; 95% CI, 0.1-0.8; P= 0.012) and re-MI (HR, 0.25; 95% CI, 0.1-1.1, P= 0.072). Moreover, even with the limit of the low number of events, ticagrelor did not significantly increase the incidence of MB (HR, 1.49; 95% CI, 0.70-3.0; P= 0.257). At multiple Cox regression, age (HR, 1.03; 95% CI, 1.02-1.05; P< 0.001) resulted an independent risk factor for bleeding. In our study, reflecting the results from two large retrospective, real-world registries, Ticagrelor did not significantly increase MB compared with clopidogrel in elderly patients with ACS treated with PCI, while significantly improving 1-year survival. Further studies on elderly patients are suggested.

Is Sepsis a Risk Factor for Bleeding in Adults with Hematologic Malignancies?

BackgroundThe TOPPS trial (Trial of Prophylactic vs. No-Prophylactic Platelet Transfusions in Patients with Haematological Malignancies) provides a resource to explore to what degree different patient factors or clinical characteristics are important prognostic factors for bleeding. A previous analysis of the TOPPS data has looked at risk factors for bleeding on data that was collected at all study centres, this included: female sex; hematologic diagnosis; treatment for their hematologic diagnosis; and TOPPS treatment arm (prophylaxis/no-prophylaxis).This study aims to look at additional factors that were not assessed in previous analyses of TOPPS data.MethodsWe collected additional data on potential risk factors for bleeding at two study centres (Oxford and Glasgow) on 219 patients with a total of 3454 observations, as a sub-study of the TOPPS trial (ISRCTN08758735). Bleeding information was reported for over 95% of study days. It was necessary to remove all study day 1 observations (as previous day lab values were not know), therefore 3084 observations were included in the recurrent event analysis.We collected additional data on: Hb; WCC; albumin; bilirubin; creatinine; use of antibiotics; use of antifungals; admission to ITU; use of oxygen; CRP; temperature. This additional data was only available while patients were inpatients, however most bleeds that occurred during the TOPPS trial occurred while the patient was in hospital (94%). Only the first day of consecutive bruising or petechiae was counted as a bleed, unless bleeding on the subsequent day was worse.Bleeding assessments were performed daily and assessed bleeding over the preceding 24 hours. The blood results performed on the day prior to the bleeding assessment were in the same 24 hour period as any bleeding occurred. Analyses were performed that took missing data into account or only included the full data set. Variables considered in the model were: female sex, hematologic diagnosis; treatment for their hematologic diagnosis; TOPPS treatment arm; age; platelet count; relapsed disease; previous HSCT; Hb; WCC; albumin; bilirubin; creatinine; use of antibiotics; use of antifungals; admission to ITU; use of oxygen; CRP; temperature.ResultsBaseline characteristics were similar to all patients within the TOPPS study. The only differences noted between the Oxford and Glasgow groups and the overall study were: higher proportion of patients receiving an allogeneic HSCT; and a higher proportion of patients with a co-existing disorder or organ failure (13% vs. 7%). The median number of days with a WHO grade 2-4 bleed was 0 days (IQR 0 to 1).In the univariate analysis: TOPPS treatment arm (P = 0.02); female sex (P = 0.002); previous HSCT (P = 0.03); previous day C-reactive protein (CRP) (P < 0.0001); previous day Hb (p < 0.0001); previous day WCC (P < 0.0001); previous day creatinine (P < 0.0001); treatment with therapeutic antibiotics (P < 0.0001); ITU/HDU admission (P = 0.04); oxygen treatment (P < 0.0001); high temperature (P = 0.02); and previous day's platelet count were associated with bleeding (P < 0.0001).In the multivariate recurrent event analyses we investigated factors associated with the hazard of a grade 2 to 4 bleed on any one day. Female sex (hazard ratio (HR) 1.7 ; 95% CI 1.3 to 2.2; P < 0.0001); previous day platelet count (0 to 20 x 109/L versus > 50 x 109/L: HR 3.3; 95% CI 1.4 to 7.9; P = 0.0002), previous day CRP (100 to 150 versus 0 to 9 mg/L: HR 1.7; 95% CI 1.0 to 3.0; P = 0.03); previous day creatinine (121 to 180 versus 0 to 90 µmol/L: HR 1.9; 95% CI 1.3 to 2.8: P = 0.02); and previous day WCC (0 to 0.4 x 109/L versus > 3.4 x 109/L: HR 2.6; 95% CI 1.4 to 5.0; P = 0.005) were all found to be significantly associated with bleeding in both analyses. TOPPS treatment arm was found to be significant in the full data set analysis (no-prophylaxis versus prophylaxis: HR 1.3; 95% CI 1.0 to 1.7; P = 0.04) but not in the analysis that included missing data.DiscussionThis new analysis of the TOPPS data set identified additional independent risk factors for bleeding that have not been previously identified, these were CRP and low white cell count. It also confirmed risk factors identified in previous analyses on the TOPPS data as well as other clinical trial data sets. CRP was the only significant sepsis-related risk factor. The next step is to use data from this and other analyses to develop a simple model that can stratify patients into different bleeding risk categories.FundingNHSBT DisclosuresNo relevant conflicts of interest to declare.

Risk factors for bleeding in patients with acute necrotizing pancreatitis undergoing endoscopic necrosectomy.

This study investigated risk factors for bleeding in patients with acute necrotizing pancreatitis (ANP) undergoing endoscopic necrosectomy (EN) and the effect of endoscopic haemostasis. 145 patients with ANP who underwent EN were recruited from January 2014 to December 2018. Patients with and without bleeding were allocated to the bleeding and nonbleeding groups, respectively. Multivariable logistic regression models were used to assess independent risk factors for bleeding. 39 patients (26.9%) experienced bleeding. The body mass index and culture-confirmed infectious pancreatic necrosis (IPN), renal failure and continuous renal replacement therapy rates were significantly higher in the bleeding group (all P<0.01). In addition, the number of debridement procedures was significantly higher in the bleeding group (P=0.004), accompanied by a higher mortality rate and greater hospitalization costs (all P<0.05). Most cases of bleeding during EN were successfully stopped by endoscopic haemostasis (94.1%), but this was difficult to achieve after EN. Multivariate analysis revealed that renal failure (odds ratio [OR]: 3.77, P=0.02), culture-confirmed IPN (OR: 3.19, P=0.02), and ≥3 debridement procedures (OR: 12.92, P=0.001) were associated with an increased bleeding risk. Renal failure, culture-confirmed IPN, and multiple debridement procedures were independent risk factors for bleeding in patients with ANP who underwent EN.

ADP-induced platelet reactivity and bleeding events in patients with acute myocardial infarction complicated by cardiogenic shock

While previous reports showed ADP-induced platelet reactivity to be an independent predictor of bleeding after PCI in stable patients, this has never been investigated in patients with cardiogenic shock. The association of bleeding events with respect to ADP-induced platelet aggregation was investigated in patients undergoing primary PCI for acute myocardial infarction complicated by cardiogenic shock and with available on-treatment ADP-induced platelet aggregation measurements. Out of 233 patients, 74 suffered from a severe BARC3 or higher bleed. ADP-induced platelet aggregation was significantly lower in patients with BARC≥3 bleedings (p < .001). Multivariate analysis identified on-treatment ADP-induced platelet aggregation as an independent risk factor for bleeding (HR = 0.968 per AU). An optimal cutoff value of <12 AU for ADP-induced platelet aggregation to predict BARC≥3 bleedings was identified via ROC analysis. Moreover, the use of VA-ECMO (HR 1.972) or coaxial left ventricular pump (HR 2.593), first lactate (HR 1.093 per mmol/l) and thrombocyte count (HR 0.994 per G/l) were independent predictors of BARC≥3 bleedings. In conclusion, lower on-treatment ADP-induced platelet aggregation was independently associated with severe bleeding events in patients with AMI-CS. The value of platelet function testing for bleeding risk prediction and guidance of anti-thrombotic treatment in cardiogenic shock warrants further investigation.

ADP-induced platelet reactivity and bleeding events in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Funding Acknowledgements Type of funding sources: None. Background While previous reports showed ADP-induced platelet reactivity to be an independent predictor of bleeding after PCI in stable patients, this has never been investigated in patients with cardiogenic shock (CS). Methods The association of bleeding events with respect to ADP-induced platelet aggregation was investigated in patients undergoing primary PCI for acute myocardial infarction complicated by cardiogenic shock (AMI-CS) and with available on-treatment ADP-induced platelet aggregation measurements. Results Out of 233 patients, 74 suffered from a severe BARC 3 or higher bleed. ADP-induced platelet aggregation was significantly lower in patients with BARC≥3 bleedings (10 AU [IQR 3 - 13] vs. 15 AU [IQR 9 - 25], p &amp;lt; 0.001). Multivariate analysis identified on-treatment ADP-induced platelet aggregation as an independent risk factor for bleeding (HR = 0.968 per AU, 95% confidence interval (CI) 0.942-0.994). An optimal cut-off value of &amp;lt;12 AU for ADP-induced platelet aggregation to predict BARC≥3 bleedings was identified via ROC analysis. Moreover, use of VA-ECMO (HR 1.972, 95% CI 1.003-3.879) or coaxial left ventricular pump (HR 2.593, 95% CI 1.509-4.455), first lactate (HR 1.093 per mmol/l, 95% CI 1.037-1.152) and thrombocyte count (HR 0.994 per G/l, 95% CI 0.990-0.998) were independent predictors of BARC≥3 bleedings. There was no significant difference in survival nor ischemic events between patients with low and high on-treatment platelet reactivity. Conclusion: Lower on-treatment ADP-induced platelet aggregation was independently associated with severe bleeding events in patients with AMI-CS. The value of platelet function testing for bleeding risk prediction and guidance of anti-thrombotic treatment in CS warrants further investigation.

Bivalirudin in patients undergoing percutaneous coronary intervention and independent predictors of postoperative adverse events in these patients: A real world retrospective study.

The efficacy and safety of bivalirudin in percutaneous coronary intervention (PCI) has always been a hot topic in perioperative antithrombotic therapy, but there are still some controversies. So studies are needed to provide more evidence, especially the real world study which includes patients excluded from previous RCT studys. Our study aimed to investigate these information and analyze the independent predictors of postoperative adverse events.A retrospective study enrolled 1416 patients underwent PCI in Tianjin Chest Hospital from May 2016 to October 2017. The incidence of stent-thrombosis and net clinical adverse events, including all-cause death, myocardial infarction, stroke, urgent target-vessel revascularization and bleeding, were followed up for 30 days and 1 year. Logistic regression and COX regression were respectively used to analyze independent predictors of bleeding events within 30-days, and independent predictors of Major adverse cardiovascular and cerebrovascular events (MACCE) in patients with stent implantation within 1-year.Seven hundred six patients were treated with bivalirudin while 710 with unfractionated heparin (UFH). The proportions of diabetes, hypertension, anemia, myocardial-infarction history, PCI history, moderate-to-severe renal-impairment, gastrointestinal-bleeding history in the bivalirudin group were significantly higher (P < .05). Women, anemia were independent risk factors for bleeding within 30-days (P < .05). Among 682 patients with stent implantation in bivalirudin group, anemia, Body Mass Index (BMI) >25 kg/m2, KILLIP ≥2, ejection fraction (EF) <45%, eGFR <60 ml/minutes were independent risk factors for MACCE, while Statins, proton pump inhibitor (PPI) were independent protective factors for MACCE with-in 1-year (P < .05).Bivalirudin have good anticoagulant effect and lower bleeding risk during PCI, especially in patients with higher bleeding risk. In patients treated with bivalirudin, female, anemia were independent predictors of bleeding within 30-days, BMI >25 kg/m2, anemia, KILLIP ≥2, EF <45%, eGFR <60 ml/minutes were independent risk factors and Statins, PPI were independent protective factors of MACCE within 1-year.

Criteria for low von Willebrand factor diagnosis and risk score to predict future bleeding

BackgroundImportant diagnostic and clinical aspects of moderately reduced von Willebrand factor (VWF) levels are still unknown. There is no clear evidence which cutoff value (0.50 vs 0.60 IU/ml) should be used to diagnose “low VWF.” Also, the incidence of bleeding after the diagnosis has been made, and risk factors for bleeding are unknown yet. ObjectivesTo investigate the incidence of postsurgical bleeding, postpartum hemorrhage (PPH), and traumatic and spontaneous bleeding after low VWF diagnosis, and to develop a risk score to predict future bleeding. MethodsWe performed a cohort study in patients with historically lowest VWF levels of 0.31 to 0.60 IU/ml. Clinical data of patients were retrospectively collected. ResultsWe included 439 patients with low VWF. During a follow‐up of 6.3 ± 3.7 years, 259 surgical procedures, 81 deliveries, and 109 spontaneous and traumatic bleeding episodes were reported. The incidence of postsurgical bleeding was 2.7%, whereas 10% of deliveries was complicated by PPH. Overall, 65 patients (14.8%) had bleeding requiring treatment, which was not different between patients with historically lowest VWF levels of 0.31–0.50 and 0.51–0.60 IU/ml (p = .154). Age <18 years, abnormal bleeding score at diagnosis, and being referred for bleeding symptoms at the time of diagnosis were independent risk factors for bleeding during follow‐up, and therefore included in the risk score. ConclusionsThe cutoff value of low VWF diagnosis should be set at 0.60 IU/ml. Furthermore, a risk score is developed to identify individuals with a high risk for bleeding after low VWF diagnosis.

Risk factors associated with warfarin overdose and complications related to warfarin overdose in the emergency department

The aim of this study was to investigate risk factors of bleeding and mortality in patients with warfarin overdose (WOD). Totally, 783 patients were included, of which, 272 patients (34.7%) with an INR below 5,364 patients (46.5%) with an INR between 5–10, and 147 patients (18.8%) with an INR of 10 or above. Demographic, clinical, and laboratory findings of the patients were obtained from the Real Life Data Provision Center and Hospital Information Management System. Admittance in autumn (OR = 1.75; p = 0.012), INR = 5–10 (OR = 2.65; p < 0.001), INR ≥ 10 (OR = 9.06; p < 0.001), and antiplatelet use alongside warfarin (OR = 1.93; p < 0.001) were found to be independent risk factors for bleeding in this study. The age (OR= 1.03; p = 0.005), bleeding (OR = 1.69; p = 0.020), primary hypertension (OR = 1.72; p = 0.031), and INR ≥ 10 (OR = 2.02; p = 0.025) were found to be independent risk factors for mortality. The cutoff value for INR in predicting bleeding was found to be >6.35 with 74.2% sensitivity and 72.7% specificity. The significant risk factors were determined in WOD development. INR level, autumn, and antiplatelet use were independently associated with bleeding due to WOD. In addition, bleeding, hypertension and INR levels were independently related to in-hospital-mortality due to WOD.

Prognostic Impact of Cancer Activity on Clinically Relevant Bleeding Events After Percutaneous Coronary Intervention.

Purpose : Limited data exist about clinically relevant bleeding events related to antiplatelet therapy after percutaneous coronary intervention (PCI) in cancer patients. We investigated the risk factors for clinically relevant bleeding events in patients with cancer after PCI with stent implantation. Patients and Methods : Patients with solid cancer subjected to first PCI were divided into active (n = 45) and non-active cancer groups (n = 44). The active group included non-operable patients on treatment or with metastasis ; the non-active included those already subjected to or for whom radical surgery was planned within 3 months after the index PCI. Results : During a median follow-up of 2.2 years, 11 bleeding events occurred, with only one occurring in the non-active cancer group. Half of them occurred during the dual-antiplatelet therapy (DAPT) period, and the rest occurred during single-antiplatelet therapy (SAPT) period. Kaplan-Meier analysis showed significantly more bleeding events in the active cancer group (p = 0.010). Multivariate Cox regression hazard analysis revealed cancer activity as a significant independent risk factor for bleeding (p = 0.023) ; but not for three-point major adverse cardiovascular events. Conclusion : Clinically relevant bleeding risk after PCI was significantly lower in non-active cancer. Active cancer group had clinically relevant bleeding during both DAPT and SAPT periods. J. Med. Invest. 68 : 29-37, February, 2021.

Risk factors for intraoperative hemorrhage during cesarean myomectomy

ObjectiveWe intended to identify the risk factors of intraoperative hemorrhage on occasions of a combined operation of myomectomy with cesarean section for patients with uterine leiomyoma. Materials and methodsA retrospective cohort study was done of all patients who underwent cesarean myomectomy for intramural leiomyoma at a single university hospital. Cases identified with subserosal leiomyoma, placental disorder, and comorbid conditions related to coagulopathy were excluded. All the included cases were classified into intraoperative hemorrhage and non-hemorrhage group. Obstetric and demographic factors and parameters of leiomyoma were compared between two groups. ResultsA total of 302 women underwent cesarean myomectomy during the study period. Among these women, 212 pregnant women met the inclusion criteria. Intraoperative hemorrhage occurred in 43 women (20.3%). There was no significant intergroup difference in the number of removed leiomyomas. Multiple logistic regression analysis demonstrated that lower segmental location (odds ratio [OR], 2.827; 95% confidence interval [CI], 1.033–7.734, P = 0.043) and the diameter (OR, 1.167; 95% CI, 1.044–1.305, P = 0.006) were significant independent risk factors for hemorrhage during cesarean myomectomy. The combination of ≥ 8 cm diameter or lower segmental position of the leiomyoma yielded a specificity of 79.3% for operative hemorrhage during cesarean myomectomy. The negative predictive value of this combination was 88.7% for operative hemorrhage with a prevalence of 20%. ConclusionThe large size and lower segmental position of the leiomyoma are significantly risk factors for intraoperative hemorrhage during cesarean myomectomy. If the leiomyoma is located in the uterine fundus or body and its diameter is less than 8 cm, the removal of leiomyoma may be considered at the time of cesarean section.

CD62P (P-selectin) expression as a platelet activation marker in patients with liver cirrhosis with and without cholestasis.

Aim of the studyP-selectin (CD62P) is a platelet activation marker that was claimed to mediate the accumulation of platelets induced by cholestasis. The nature of platelet dysfunction and hemostasis abnormalities in cholestatic liver disease needs to be more explored. The aim of this study was to assess platelet CD62P expression in cirrhotic patients with and without cholestasis, and to evaluate its relationship with a bleeding tendency.Material and methods150 patients were included in this case-control study. Participants were divided into 84 patients with liver cirrhosis (group I), 44 of whom had cholestasis (Group Ia) and 40 patients were without cholestasis (group Ib); 36 patients who were cholestatic without liver cirrhosis (group II); and 30 healthy subjects who formed the control group (group III). Platelet CD62P expression was assessed by a flow cytometer.ResultsPlatelets expressing CD62P were significantly increased in all patient groups compared to controls (p < 0.001). Platelets expressing CD62P were significantly increased in gastrointestinal (GIT) bleeders compared to non-bleeders in cirrhotic and cholestatic groups (p < 0.001 each). Among group I patients at cut-off > 12.4, up-regulation of platelet CD62P yielded 72% sensitivity and 44.1% specificity to discriminate bleeders from non-bleeders (p = 0.01), while among group II at cut-off > 12.9, it yielded 90% sensitivity and 80.8% specificity (p < 0.001). In cirrhotic patients, platelet CD62P expression was significantly increased in patients with an advanced Child-Pugh class (p < 0.001). Platelet expressing CD62P was shown as an independent risk factor for bleeding among cirrhotic cases with an odds ratio of 1.07 and CI 0.99-1.15.ConclusionsUp-regulation of platelet CD62P expression can serve as a GIT bleeding predictor in liver cirrhosis.