Post-discharge Bleeding Research Articles

An external validation of DOAC score in patients with atrial fibrillation following transcatheter aortic valve replacement

Abstract Background Bleeding events, particularly in patients with atrial fibrillation (AF) and those with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), are a major clinical concern and are associated with a worse prognosis. The DOAC Score (1) has recently been introduced to predict bleeding risk in patients with AF taking direct oral anticoagulants (DOACs). However, further validation is required to confirm its ability. Objective This study aims to evaluate the predictive ability of the DOAC Score for bleeding events in Asian patients with AF undergoing TAVR. Methods In this multicentre, retrospective, observational cohort study, patients with AF who underwent TAVR were included. The data was obtained from the Japanese multicentre registry, which comprises 19 centres from 2013 to 2019. Bleeding was defined as any post-discharge bleeding after TAVR. The primary endpoint was the incidence of all bleeding events in 3 populations: the overall population, the DOAC cohort, and the vitamin K antagonist (VKA) cohort. Results This study included 1230 patients with a mean age of 84.6 ± 5.1 years, of whom 457 were males. Among them, 465 patients (37.8%) were treated with a VKA while the rest were treated with a DOAC. Patients were divided into three groups according to their DOAC Score: 380 patients (30.1%) were in the ≤ moderate risk group with a DOAC Score of 7 or less, 497 patients (40.4%) were in the high-risk group with a DOAC Score of 8 or 9, and 353 patients (28.7%) were in the very high-risk group with a DOAC Score over 10. The cumulative incidence of all bleeding at 5 years in the overall population was significantly different in the 3 risk groups: ≤ moderate: 8.4%, high-risk: 10.8%, very high-risk: 21.6%, respectively (p< 0.01). The incidence was also significantly different in the DOAC and VKA cohorts (p<0.01 and p=0.03, respectively). Conclusion The recently published DOAC Score is well predictive of bleeding risk in Asian patients with AF after TAVR. The score may be useful in predicting bleeding in patients taking both DOAC and VKA.Graphical abstract

Clinical Outcomes After Percutaneous Coronary Intervention for Left Main Coronary Artery Disease in Patients of Diverse Race/Ethnicity

Data on percutaneous coronary intervention (PCI) for left main coronary artery (LMCA) disease in patients of diverse race/ethnicity is scant. The aim of the study was to assess the impact of race/ethnicity on clinical outcomes at 12-month follow-up of patients with LMCA disease undergoing PCI with drug-eluting stent implantation. All patients undergoing PCI for LMCA disease between 2010 and 2019 at a tertiary care center were prospectively enrolled. Clinical outcomes were assessed per each race/ethnic group. The primary endpoint was the composite of all-cause death, myocardial infarction (MI), or stroke at 12 months. A total of 774 consecutive patients with known race/ethnicity were prospectively enrolled, 62.1% (n=481) Caucasians, 17.2% (n=133) Hispanics, 12.7% (n=98) Asians and 8.0% (n=62) African Americans. Compared with Caucasians, the hazard rate of the primary endpoint tended to be lower in Asian patients (6.1% vs 14.2%; hazard ratio [HR]: 0.41; 95% confidence interval [CI]: 0.16-1.03), and similar in African American (13.7% vs 14.2%; HR: 0.93; 95% CI: 0.40-2.16) and Hispanic patients (14.2% vs 14.2%; HR: 1.02; 95% CI: 0.58-1.78). Hazard rates of target vessel or lesion revascularization were comparable in the four groups. Cox multivariable regression adjustment confirmed consistent findings and revealed higher hazard rate of post-discharge bleeding in African Americans vs. Caucasians (HR: 5.89; 95% CI: 1.00-34.5). In conclusion, within a racially/ethnically diverse cohort of patients undergoing PCI for LMCA disease, when compared with Caucasians, Asians are at lower risk of all-cause death, MI or stroke, while African Americans are at increased risk of post-discharge bleeding.

De-escalation of antithrombotic treatment after acute coronary syndrome, a new paradigm.

After an acute coronary syndrome (ACS) it is imperative to balance the bleeding vs. the ischemic risk given the similar prognostic impact of the two events. Since the post-discharge bleeding risk is substantially stable over time whereas the ischemic risk accumulates in the first weeks to months, a strategy of de-escalation of antithrombotic treatment, consisting in the reduction of either the duration (i.e., early interruption of one antiplatelet agent) or the intensity (i.e., switching from the more potent P2Y12-inhibitors prasugrel or ticagrelor to clopidogrel) of dual antiplatelet therapy (DAPT), has been proposed. Reducing the intensity of DAPT can be carried out as a default strategy (unguided approach) or based on the results of either platelet function tests or genetic tests (guided approach). Overall, all de-escalation strategies have shown to consistently decrease bleeding events with no apparent increase in ischemic events as compared to 12-month standard-of-care DAPT. Owing however to several limitations and weaknesses of the available evidence, de-escalation strategies are currently not recommended as a routine, but should rather be considered for selected ACS patients, such as those at increased risk of bleeding.

PRECISE-DAPT, ARC-HBR, or Simplified Clinical Evaluation for the Prediction of Major Bleeding After Percutaneous Coronary Intervention in older Patients

Elderly patients have been remarkably under-represented in bleeding risk cohorts. Thus, the PRECISE-DAPT and ARC-HBR scores are not validated in older adults. Therefore, we sought to evaluate the PRECISE-DAPT and ARC-HBR scores in an exclusively elderly population and furthermore assess the prognostic value of a truly simplified clinical evaluation (SCE), consisting of only 3 binary clinical variables (hemoglobin <11g/dL, prior bleeding and anticipated use of anticoagulants). This is a retrospective analysis of the prospective single-center Elderly-HCD registry. Consecutive patients of ≥75 years of age that underwent percutaneous coronary intervention in the period of 2012-2019 were included. The primary endpoint was post discharge bleeding (PDB) at 12 months follow-up, defined according to the BARC 3/5 criteria. A total of 693 patients with a mean age of 81 (± 4.4) years were included in the study and 60 (6.8%) patients met the primary endpoint. The PRECISE-DAPT and ARC-HBR scores did not significantly predict PDB in Cox-regression models (HR: 1.65 (0.78-3.42) and 1.46 (0.72-4.24), respectively), whereas the SCE outperformed both scores (HR: 2.47 (1.34-4.49)). All 3 scores exhibited a moderate discriminatory potential as determined by ROC-curve analysis (AUCs 0.601, 0.621 and 0.616, respectively) with no significant differences when comparing either of them. The SCE showed an IDI of 0.25, p=0.02 (SCE vs ARC-HBR) and 0.24, p=0.01 (SCE vs PRECISE-DAPT); with NRI of 6.54%, p=0.37 and 7.12%, p=0.43, respectively. In conclusion, both the PRECISE-DAPT score and ARC-HBR criteria showed insufficient predictive value in older adults. A truly SCE, consisting of 3 easily accessible variables, not only provides equal discriminatory potential but also demonstrates superior predictive value as determined by cox-regression models. This makes it a highly appealing tool for risk stratification, pending its evaluation in larger prospective studies.

Extended Post Discharge Prophylaxis for Venous Thromboembolism Prevention After Bariatric Surgery.

The utility of routine post-discharge VTE prophylaxis after bariatric surgery remains a matter of debate. While inpatient chemical prophylaxis decreases the risk of fatal pulmonary embolism, most thromboembolic events occur after discharge and carry high morbidity and mortality. To address this risk, apixaban was introduced as extended prophylaxis for 30days after surgery. The study ranges between 1/2014 and 7/2022. Apixaban was incorporated as routine extended prophylaxis protocol in 05/2017 and is dosed at 2.5mg BID for 30days. There were two study groups: those who received apixaban on discharge (n = 1443; 60%) and those who did not (n = 953; 40%). Patients with concern for postoperative bleeding (hypotension, unexplained tachycardia with hematocrit drop > 6%, hematocrit drop > 9%), or on preoperative anticoagulant/antiplatelet therapy (except aspirin), were not discharged on apixaban. Post-discharge VTE, readmission, transfusion, and reoperation rates were compared between groups. There were 2396 consecutive primary bariatric operations: sleeve gastrectomy (1949; 81%), Roux-en-Y gastric bypass (419; 18%), and duodenal switch (28; 1%). There were no post-discharge VTEs in patients treated with apixaban vs. five (0.5%) VTEs in patients who did not receive treatment; p = 0.02. There was a higher incidence in post-discharge bleeding events in the apixaban group (0.5 vs 0.3%; p = 0.75), mostly requiring readmission for monitoring without intervention or transfusion. In the apixaban group, one patient underwent EGD for bleeding while another required blood transfusion; there were no reoperations for bleeding. There were no post-discharge VTEs in patients who received apixaban. Treatment was associated with a higher risk of self-resolving bleeding events. This study adds to the increasing body of evidence supporting the benefit of routine, extended oral chemoprophylaxis after bariatric surgery.

Incidence and Outcome of Post-Discharge Bleeding After Percutaneous Coronary Intervention in Acute Ischemic Patients

Incidence and Outcome of Post-Discharge Bleeding After Percutaneous Coronary Intervention in Acute Ischemic Patients

Venous Thromboembolism in Total Hip and Total Knee Arthroplasty

The optimal pharmacologic thromboprophylaxis agent after total hip and total knee arthroplasty is uncertain and consensus is lacking. Quantifying the risk of postoperative venous thromboembolism (VTE) and bleeding and evaluating comparative effectiveness and safety of the thromboprophylaxis strategies can inform care. To quantify risk factors for postoperative VTE and bleeding and compare patient outcomes among pharmacological thromboprophylaxis agents used after total hip and knee arthroplasty. This retrospective cohort study used data from a large health care claims database. Participants included patients in the United States with hip or knee arthroplasty and continuous insurance enrollment 3 months prior to and following their surgical procedure. Patients were excluded if they received anticoagulation before surgery, received no postsurgical pharmacological thromboprophylaxis, or had multiple postsurgery thromboprophylactic agents. In a propensity-matched analysis, patients receiving a direct oral anticoagulant (DOAC) were matched with those receiving aspirin. Aspirin, apixaban, rivaroxaban, enoxaparin, or warfarin. The primary outcome was 30-day cumulative incidence of postdischarge VTE. Other outcomes included postdischarge bleeding. Among 29 264 patients included in the final cohort, 17 040 (58.2%) were female, 27 897 (95.2%) had inpatient admissions with median (IQR) length of stay of 2 (1-2) days, 10 948 (37.4%) underwent total hip arthroplasty, 18 316 (62.6%) underwent total knee arthroplasty; and median (IQR) age was 59 (55-63) years. At 30 days, cumulative incidence of VTE was 1.19% (95% CI, 1.06%-1.32%) and cumulative incidence of bleeding was 3.43% (95% CI, 3.22%-3.64%). In the multivariate analysis, leading risk factors associated with increased VTE risk included prior VTE history (odds ratio [OR], 5.94 [95% CI, 4.29-8.24]), a hereditary hypercoagulable state (OR, 2.64 [95% CI, 1.32-5.28]), knee arthroplasty (OR, 1.65 [95% CI, 1.29-2.10]), and male sex (OR, 1.34 [95% CI, 1.08-1.67]). In a propensity-matched cohort of 7844 DOAC-aspirin pairs, there was no significant difference in the risk of VTE in the first 30 days after the surgical procedure (OR, 1.14 [95% CI, 0.82-1.59]), but postoperative bleeding was more frequent in patients receiving DOACs (OR, 1.36 [95% CI, 1.13-1.62]). In this cohort study of patients who underwent total hip or total knee arthroplasty, underlying patient risk factors, but not choice of aspirin or DOAC, were associated with postsurgical VTE. Postoperative bleeding rates were lower in patients prescribed aspirin. These results suggest that thromboprophylaxis strategies should be patient-centric and tailored to individual risk of thrombosis and bleeding.

Abstract 14598: Predictive Value of the High Bleeding Risk Criteria of the Academic Research Consortium in Black and White Individuals

Introduction: The High Bleeding Risk (HBR) criteria of the Academic Research Consortium (ARC) are a valuable tool for bleeding risk stratification in White and Asian patients undergoing percutaneous coronary intervention (PCI). Hypothesis: The predictive value of the ARC-HBR criteria may vary in Black patients. Methods: Patients who underwent PCI at a large tertiary-care center from 2012 to 2019 who self-reported as non-Hispanic White or Black were included and stratified in HBR and no-HBR based on the ARC-HBR definition. The primary outcome was major bleeding (according to a study specific definition) at 1 year after PCI; secondary outcomes included post-discharge major bleeding, all-cause death and myocardial infarction (MI). Results: Among 9462 patients, 1881 (19.9%) identified as Black and 7581 (80.1%) as White. In these two groups, the HBR criteria were met by 50.8% and 45.6% of patients, respectively, and the frequency of each individual ARC-HBR criterion differed (Figure 1). HBR was associated with a consistent higher risk of major bleeding in Black (7.8% vs. 3.5%, adj. HR 2.02, 95% CI 1.29-3.17) and White patients (7.5% vs. 2.7%, adj. HR 2.49, 95% CI 1.95-3.18, interaction p-value 0.451) (Figure 1). The HBR-related risk of post-discharge bleeding tended to be higher in Black patients (adj. HR 1.67, 95% CI 0.84-3.33) and was significantly increased in White patients (adj HR 3.09, 95% 2.06-4.64, interaction p-value 0.341). All-cause death and MI were increased in HBR patients consistently in the Black and the White group. The predictive value of the ARC-HBR criteria for major bleeding and post-discharge bleeding was good in both Black (0.72 and 0.74, respectively) and White (0.70 and 0.68, respectively). Conclusions: In Black and White patients undergoing PCI, the ARC-HBR criteria were differently distributed and had a good predictive value for major bleeding in both groups.

Venous Thromboembolism Prophylaxis in Otolaryngologic Patients Using Caprini Assessment.

The aim was to determine the utilization of Caprini guideline-indicated venous thromboembolism (VTE) prophylaxis and impact on VTE and bleeding outcomes in otolaryngology (ORL) surgery patients. Elective ORL surgeries performed between 2016 and 2021 were retrospectively identified. Logistic regression models were used to examine the association between patient characteristics and receiving appropriate prophylaxis, inpatient, 30- and 90-day VTE and bleeding events. A total of 4955 elective ORL surgeries were analyzed. Thirty percent of the inpatient cohort and 2% of the discharged cohort received appropriate risk-stratified VTE prophylaxis. In those who did not receive appropriate prophylaxis, overall inpatient VTE was 3.5-fold higher (0.73% vs. 0.20%, p = 0.015), and all PE occurred in this cohort (0.47% vs. 0.00%, p = 0.005). All 30- and 90-day discharged VTE events occurred in those not receiving appropriate prophylaxis. Inpatient, 30- and 90-day discharged bleeding rates were 2.10%, 0.13%, and 0.33%, respectively. Although inpatient bleeding was significantly higher in those receiving appropriate prophylaxis, all 30- and 90-day post-discharge bleeding events occurred in patients not receiving appropriate prophylaxis. On regression analysis, Caprini score was significantly positively associated with likelihood of receiving appropriate inpatient prophylaxis (odds ratio [OR] 1.05, confidence interval [CI] 1.03-1.07) but was negatively associated in the discharge cohort (OR 0.43, CI 0.36-0.51). Receipt of appropriate prophylaxis was associated with reduced odds of inpatient VTE (OR 0.24, CI 0.06-0.69), but not with risk of bleeding. Although Caprini VTE risk-stratified prophylaxis has a positive impact in reducing inpatient and post-discharge VTE, it must be balanced against the risk of inpatient postoperative bleeding. 3 Laryngoscope, 134:1169-1182, 2024.

Can Risk-Based Thromboprophylaxis Practice Guidelines be Safely Used in Esophagectomy Cases? Experience of an Academic Health System

BackgroundVenous thromboembolism (VTE) occurs in 3–11% of esophagectomy patients and is associated with increased mortality and morbidity. The use of validated VTE risk assessment tools and compliance with recommended practice guidelines remains unclear. In this study, we seek to determine the use of Caprini guideline indicated VTE prophylaxis and its effect on VTE and bleeding complications following esophagectomy. MethodsEsophagectomy cases were identified from the Mayo Clinic electronic health records. Caprini score and VTE prophylaxis regimen received were determined retrospectively. VTE prophylaxis was identified as appropriate or inappropriate based on the Caprini score and prophylaxis received preoperative, during hospitalization, and after hospital discharge. Study cohorts were compared by Pearson Chi-square test, Fisher’s Exact test, Kruskal–Wallis test, and logistic regression models. Stata/MP 16.1 was used for analysis. Odds ratios and 95% confidence intervals were reported for logistic regression models. A p-value < 0.05 was considered significant. ResultsFour hundred and fifty-six esophagectomy cases were analyzed. The median Caprini score was thirteen. Appropriate prophylaxis resulted in a 6.9-fold reduction in inpatient VTE. All 30- and 90-day post-discharge VTEs occurred in those not receiving Caprini guideline-indicated VTE prophylaxis. Inpatient, 30- and 90-day post-discharge bleeding rates were 7.68%, 0.91%, and 2.11%, respectively; however, bleeding was not increased with receipt of appropriate prophylaxis. ConclusionIn this esophagectomy cohort, Caprini guideline indicated VTE prophylaxis resulted in reduced inpatient VTE events without increasing bleeding complications. Risk-based VTE prevention measures should be considered in this patient cohort known to be at heightened risk for postoperative VTE.

Implications of bleeding on subsequent cardiovascular events in patients with atrial fibrillation after acute coronary syndrome or PCI

IntroductionThe association between bleeding and subsequent major adverse cardiac and cerebrovascular events (MACCE) remains poorly characterized. We aimed to evaluate the impact of hemorrhagic events in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). Materials and methodsA total of 1877 consecutive patients with AF and ACS or undergoing PCI were prospectively recruited. The primary endpoint was MACCE, including all-cause death, myocardial infarction, ischemic stroke, systemic embolism or ischemia-driven revascularization during follow-up. Post-discharge bleeding was graded according to TIMI criteria. Associations between bleeding and subsequent MACCE were examined using time-dependent multivariate Cox regression after adjusting for baseline covariates and the time from bleeding. ResultsDuring a median follow-up of 34.2 months, 341 (18.2 %) had TIMI major or minor bleeding events, of whom 86 (25.2 %) also experienced MACCE. The risk of MACCE was significantly higher in patients with bleeding than those without (8.85 % versus 6.99 % per patient-year; HR, 1.568, 95 % CI, 1.232–1.994). In patients who had both bleeding and MACCE, 65.1 % (56 of 86) bleeding events occurred first. Temporal gradients in MACCE risk after major bleeding was highest within 30 days (HRadj, 23.877; 95 % CI, 12.810–44.506) and remained significant beyond 1 year (HRadj, 3.640; 95 % CI, 1.278–10.366). Minor bleeding was associated with increased risk of MACCE within 1 year. ConclusionsIn patients with AF and ACS or PCI, major and minor bleeding were associated with subsequent MACCE with time-dependency. Our findings may aid in better defining net clinical benefit of optimal antithrombotic therapy.

TCTAP A-042 An Umbrella Review of the Meta Analyses About Risk and Protective Factors for Post-discharge Bleeding Events in Percutaneous Coronary Intervention Setting

TCTAP A-042 An Umbrella Review of the Meta Analyses About Risk and Protective Factors for Post-discharge Bleeding Events in Percutaneous Coronary Intervention Setting

PS-C05-5: CLINICAL IMPACT OF CREDO-KYOTO RISK SCORE ON IN-HOSPITAL BLEEDING IN PATIENTS WITH ACUTE CORONARY SYNDROME

Background: CREDO-Kyoto bleeding risk score was developed to predict the post-discharge bleeding events in patients with percutaneous coronary intervention. However, there were limited reports of the effectiveness of this score to predict the in-hospital bleeding events in patients with acute coronary syndrome (ACS). Methods: We evaluated 562 consecutive ACS patients in Saga university hospital between 2014 and 2019. Primary outcome was major bleeding during hospitalization. Major bleeding was defined as the GUSTO moderate/severe bleeding. Patients were classified into three groups according to the CREDO-Kyoto bleeding risk score (low, intermediate and high). Results: Major bleeding events occurred in 12.1% of all patients during hospitalization. Patients in the high risk group (n = 22) had significantly higher incidence of major bleeding than those in the intermediate (n = 113) and the low risk groups (n = 427) (22.7%, 18.6%, versus 9.8%, respectively, p = 0.02). Multivariate analysis showed that intermediate and high risk groups were independent predictors for the in-hospital major bleeding. Conclusions: CREDO-Kyoto risk score successfully identified high risk ACS patients for the major bleeding during hospitalization.

Incidence, Timing, and Causes of Late Bleeding After TAVR in an Asian Cohort.

Data regarding the incidence, predictive factors, and clinical outcomes of post-transcatheter aortic valve replacement (TAVR) bleeding is limited in the Asian cohort. This study sought to assess the predictors and prognostic impact of post-TAVR late bleeding. This study used the Japanese multicenter registry data to analyze 2,518 patients (mean age: 84.3 ± 5.2 years) who underwent TAVR. Late bleeding was defined as any postdischarge bleeding events after TAVR. Baseline characteristics, predictive factors, and clinical outcomes including death and rehospitalization were assessed in patients with and without late bleeding events. The cumulative incidence rate of all and major late bleeding and ischemic stroke were 7.4%, 5.2%, and 3.4%, respectively, 3 years after TAVR. The independent predictive factors of late bleeding were low platelet count, high score (≥4) on the clinical frailty scale, and a New York Heart Association functional class III/IV. The cumulative mortality rates up to 3 years were significantly higher in patients with late bleeding than in those without bleeding (P< 0.001). The multivariate Cox regression analysis revealed that late bleeding, included as a time-varying covariate in the model, was associated with an increased risk of mortality following TAVR (HR: 5.63; 95%CI: 4.28-7.41; P< 0.001). Late bleeding after TAVR was not a rare complication, and it significantly increased long-term mortality. It should be carefully managed, especially when it is predictable in the high-risk cohort, and efforts should be taken to reduce bleeding complications even after a successful procedure.

Risk of Postdischarge Bleeding From Dual Antiplatelet Therapy After Percutaneous Coronary Intervention Among US Black and White Adults.

Background Dual antiplatelet therapy after percutaneous coronary intervention reduces myocardial infarctions but increases bleeding. The risk of bleeding may be higher among Black patients for unknown reasons. Bleeding risk scores have not been validated among Black patients. We assessed the difference in bleeding risk between Black and White patients along with the performance of the Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Anti Platelet Therapy, Patterns of Nonadherence to Antiplatelet Regimens in Stented Patients, and Academic Research Consortium for High Bleeding Risk scores among both groups. Methods and Results This was a single-center prospective study of patients who underwent percutaneous coronary intervention (2014-2019) and were followed for 1 year. The outcome was postdischarge Bleeding Academic Research Consortium 2 to 5 bleeding. Incidence rates were reported. Cox proportional hazards models measured the effect of self-reported Black race on bleeding and determined the predictors of bleeding among 19 a priori variables. The 3 risk scores were assessed among Black and White patients separately using the Harrell concordance index. Of 1529 included patients, 342 (22.4%) self-reported as being Black race. Unadjusted bleeding rates were 22.7 per 100 person-years among Black patients versus 16.3 among White patients (hazard ratio, 1.41 [95% CI, 1.00-2.00], P=0.052). Predictors of bleeding were age, glomerular filtration rate <30 mL/min per 1.73 m2, prior bleeding, ticagrelor or prasugrel use, and anticoagulant use. Among Black and White patients, respectively, the C-indexes were the following: 0.644 versus 0.600 for Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Anti Platelet Therapy (P<0.001 for both), 0.620 versus 0.612 for Patterns of Nonadherence to Antiplatelet Regimens in Stented Patients (P=0.003 and P<0.001, respectively), and 0.600 versus 0.598 for Academic Research Consortium for High Bleeding Risk (P=0.006 and P<0.001, respectively). Conclusions The risk of dual antiplatelet therapy-associated postdischarge Bleeding Academic Research Consortium 2 to 5 bleeding was not significantly different between self-reported Black and White patients. Bleeding risk scores performed similarly among both groups.

B-type natriuretic peptide is associated with the occurrence of bleeding events in heart failure patients with a history of coronary artery disease

Background: Bleeding risk in heart failure (HF) patients with coronary artery disease (CAD) has not yet been fully investigated. Methods: We analyzed the data of 677 patients with a previous history of CAD who were hospitalized for HF. The patients were divided into three groups based on the tertiles of B-type natriuretic peptide (BNP) levels: Low, Middle, and High BNP groups (n = 225, 226, and 226, respectively). The primary endpoint was post-discharge bleeding events, which was defined as hemorrhagic stroke and gastrointestinal bleeding. Results: The High BNP group was the oldest (Low, Middle, High, 67.0, 74.0, and 75.0 years, respectively; p < 0.001), showed the lowest left ventricular ejection fraction (56.0%, 50.7%, and 40.3%, respectively; p < 0.001), and contained more patients at high bleeding risk (HBR) defined by the simplified version of the Academic Research Consortium for High Bleeding Risk (ARC-HBR) definition (65.3%, 85.4%, and 93.8%, respectively, p < 0.001). Kaplan-Meier analysis demonstrated that post-discharge bleeding events occurred most frequently in the High BNP group (log-rank p = 0.008). In the Cox proportional hazard analysis, compared to the Low BNP group as a reference, the High BNP group was independently associated with bleeding events after adjustment for age, sex, simplified ARC-HBR definition, and left ventricular ejection fraction (hazard ratio 3.208, 95% confidence interval 1.078–9.544, p = 0.036). Conclusions: High BNP is associated with bleeding events in HF patients with a history of CAD.

Simplified Academic Research Consortium for High Bleeding Risk (ARC-HBR) Definition Predicts Bleeding Events in Patients With Heart Failure.

It has recently been reported that the simplified Academic Research Consortium for High Bleeding Risk (ARC-HBR) definition, which excludes 6 rare criteria, is comparable to the original ARC-HBR definition in predicting major bleeding in patients with coronary artery disease (CAD) who undergo percutaneous coronary intervention. In this study, we investigated whether the simplified ARC-HBR definition could be applied to patients with heart failure (HF) to identify those at high bleeding risk (HBR).Methods and Results:In all, 2,437 patients hospitalized for HF were enrolled in this study. Patients were divided into 2 groups based on the simplified ARC-HBR definition: those at HBR (n=2,026; 83.1%) and those not (non-HBR group; n=411; 16.9%). The HBR group was older (72.0 vs. 61.0 years; P<0.001) and had a lower prevalence of CAD (31.1% vs. 36.5%; P=0.034) than the non-HBR group. Kaplan-Meier analysis showed that post-discharge bleeding events defined as hemorrhagic stroke or gastrointestinal bleeding were more frequent in the HBR than non-HBR group (log-rank P<0.001). The simplified ARC-HBR definition accurately predicted bleeding events (Fine-Gray model; hazard ratio 2.777, 95% confidence interval 1.464-5.270, P=0.001). The simplified ARC-HBR definition predicts a high risk of bleeding events in patients with HF.

Abstract 9106: Comparing the Risk of Post-Discharge Bleeding from Dual Antiplatelet Therapy, after Percutaneous Coronary Intervention, Between US Black and White Adults

Introduction: Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) reduces myocardial infarctions but increases bleeding. Guidelines recommend using risk scores to assess bleeding risk, but none have been validated in self-reported Black patients. We compared 1) post-discharge bleeding between US Black and White patients, and 2) the ability of three risk scores to predict bleeding between them. Methods: The PRiME-GGAT prospective cohort study enrolled patients (2014-2019) who underwent PCI and followed them for one year. Variables measured at PCI were included in the PRECISE-DAPT, PARIS, and ARC-HBR scores. The outcome was post-discharge BARC 2-5 events. Incidence rates were compared between Black and White patients, using incidence rate ratios (IRRs). Proportional hazards models measured the effect of self-reported Black ethnicity, adjusted for bleeding risk factors. Risk scores were compared between Black and White patients using: 1) IRRs, 2) Harrell’s C-indices, and 3) Kendall’s tau-b coefficients (τ b ). τ b was not measured for the binary ARC-HBR score. Results: Of 1529 included patients, 342 (22.4%) self-reported as Black. The incidence rate was higher among Black patients compared to White patients (22.7 versus 16.3, respectively, per 100 person-years; IRR 1.39; 95% CI, 1.01-1.90). After adjustment, self-reported Black ethnicity was not a predictor of bleeding. For both groups, IRRs were largest for PRECISE-DAPT. Between Black and White patients, respectively, C-index was 0.65 vs. 0.61 for PRECISE-DAPT, 0.63 vs. 0.61 for PARIS, and 0.60 vs. 0.59 for ARC-HBR; and τ b , respectively, was 0.71 vs. 0.64 for PRECISE-DAPT, and 0.79 vs. 0.86 for PARIS. Conclusions: Post-discharge bleeding from DAPT was greater for Black patients, compared with White patients, but this difference was not present after adjustment. PRECISE-DAPT was superior among Black patients, but PARIS was superior among White patients.

Abstract 9726: Simplified Academic Research Consortium for High Bleeding Risk Criteria Predicts Bleeding Events in Patients with Heart Failure

Introduction: It has been reported that the simplified Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria in which six rare criteria are excluded are comparable to the original ARC-HBR criteria in predicting major bleeding in patients who undergo percutaneous coronary intervention. We aimed to evaluate the predictive value of the simplified ARC-HBR criteria for bleeding events in patients with heart failure (HF) including those with and without coronary artery disease (CAD). Methods and Results: A total of 2,437 patients hospitalized for HF were enrolled. Among them, 56.5%, 23.7%, 15.8%, 4.8%, 4.7%, and 3.0% presented with oral anticoagulation, anemia, renal dysfunction, thrombocytopenia, active malignancy, and stroke of major criteria. Patients were divided into two groups based on the simplified ARC-HBR criteria: patients who are at HBR (HBR group, n = 2,026, 83.1%) and those who are not (non-HBR group, n = 411, 16.9%). The HBR group was older (72.0 vs. 61.0 years old, P &amp;lt; 0.001) and had lower prevalence of CAD (31.1% vs. 36.5%, P = 0.034) than the non-HBR group. The Kaplan-Meier analysis showed that post-discharge hemorrhagic stroke and gastrointestinal bleeding rates were higher in the HBR group than in the non-HBR group ( Figure ). In the Cox proportional hazard analysis, the simplified ARC-HBR criteria predicted both hemorrhagic stroke (hazard ratio [HR] 2.827, 95% confidence interval [CI] 1.019-7.844, P = 0.046) and gastrointestinal bleeding (HR 3.565, 95% CI 1.560-8.145, P = 0.003) irrespectively of CAD (interaction P = 0.931 and 0.761, respectively). Conclusions: The simplified ARC-HBR criteria predicts high bleeding events in patients with HF.

Post-discharge major bleeding, myocardial infarction and mortality risk after coronary artery bypass grafting: a nationwide cohort study from the SWEDEHEART registry

Abstract Background Platelet inhibition and occasionally oral anticoagulants are used after coronary artery bypass grafting (CABG) to reduce ischaemic events but may increase bleeding risk. The impact of post-discharge major bleeding and myocardial infarction on mortality risk in CABG patients is unknown. Methods All patients who underwent first-time isolated CABG in Sweden 2006–2017 and survived 14 days after discharge were included. Individual patient data from five mandatory national registries (SWEDEHEART, National Patient Register, Swedish Prescribed Drug Register, Cause of Death Register and The Swedish Population Register) were merged. Post-discharge major bleeding and myocardial infarction were defined as hospitalization with a bleeding or myocardial infarction diagnosis as main diagnosis respectively. A Cox proportional piecewise hazard model for the effect of time-updated bleeding and myocardial infarction as first post-discharge event on subsequent mortality risk was developed. The model was adjusted for age, sex, year of surgery, comorbidities at baseline and time-updated use of platelet inhibitors, oral anticoagulants and other secondary prevention medications. To estimate the time-dependent risk on mortality after an event, hazard ratios were calculated for &amp;lt;30 days, 30–365 days and &amp;gt;365 days after first incidence of major bleeding and myocardial infarction. Results In total 36 633 patients were included and median follow-up was 6.0 years (25th-75th percentile 3.0–9.0 years). During follow-up, 2265 (6.2%) patients suffered a major bleeding and 2108 (5.8%) patients a myocardial infarction as a first post-discharge event. In total 6683 (18.2%) died during follow-up. Both major bleeding and myocardial infarction were significantly associated with increased mortality risk compared to patients without any major bleeding or myocardial infarction. The adjusted hazard ratios for mortality &amp;lt;30 days after major bleeding were 21.45 (95% CI 18.27–25.20) and 22.00 (95% CI 18.29–26.45) after myocardial infarction, 4.04 (95% CI 3.57–4.56) and 4.54 (95% CI 3.88–5.31) 30–365 days after the event and 1.57 (95% CI 1.43–1.72) and 2.07 (95% CI 1.86–2.30) &amp;gt;365 days after the event, all compared to patients without major bleeding or myocardial infarction. Conclusion Major bleeding and myocardial infarction as first post-discharge event after CABG had similar incidence and were associated with a significant and comparable increase in mortality risk. The risk was highest during the first 30 days after the event. Strategies to prevent myocardial infarction and major bleeding events after CABG are of great importance to improve survival. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Swedish Heart-Lung FoundationSparbanken Sjuhärads stiftelse för forskning vid Södra Älvsborgs Sjukhus Forest plot