August 2013
PCI bleeding
New risk score could predict risk of bleeding after PCI
According to a study published in Circulation Journal, a simple risk score could be used to predict which patients are at high risk of bleeding after a percutaneous coronary intervention (PCI) procedure. Additionally, a patient’s risk of bleeding (low, intermediate, or high) could be used to direct choice of treatment (eg. bare metal stent or drug-eluting stent)
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gor Mrdovic, associate professor of Medicine and Cardiology, University of Belgrade School of Medicine, Clinical Center of Serbia, Cardiol- ogy Clinic and Emergency Hospital, Belgrade, Serbia, and others wrote that bleeding following PCI in patients with acute coronary syndromes is associated with an increased of death, myocardial
at reducing the risk of bleeding might led to a reduction in an adverse outcomes. However, they explained, at present, there is not a simple risk score for predicting the risk of bleeding in STEMI patients undergoing PCI. They wrote: “We therefore performed the present study in order to generate and validate a simple risk model for the prediction of
level (<125g/dl) at presentation, and Killip class >1 heart failure at time of admission. They then assigned points to each factor based on the risk of bleeding it conferred (eg. one point for female gender but two points for creatinine clearance). A patient’s risk of bleeding was then calculated from their total score of points (ranging from zero to eight),
infarction, and stroke at 30 days, six months, and beyond. They commented: “It is noteworthy that not only major bleeding but also moderate bleeding were significantly associated with one- year mortality.” Mrdovic et al added that an accurate bleeding prediction model “might help to determine treat- ment strategies in patients presenting with ST-segment elevation myocardial infarction (STEMI)” as measures aimed
Patients in the high-risk class should be treated prefer- ably with bare metal stents and/or a radial ap- proach, which appeared to be associated with a significant reduction in vascular complications bleeding after PCI.”
Using data from the RISK-PCI, which was a single-centre study designed to predict the risk of major adverse cardiac events at 30 days in patients treated with clopidogrel, Mrdovic et al identified five factors that were associated with an increased risk of 30-day bleeding: female gender, history of peptic ulcer, creatinine clearance (<60ml/min) at time of admission to hospital, haemoglobin
with zero points indicating a low risk of bleeding, one to two points indicating a intermediate risk of bleeding, and ≥3 points indicating a high risk of bleeding. The authors reported that there was a graded 33-fold increase in 30-day bleed- ing with increasing risk score (p<0.001). They added that the score was predictive of both access site bleeding and bleeds not associated with the access site and commented: “An 11-fold graded increase
in the primary endpoint [type ≥3 bleed in accordance with Bleeding Academic Research definition not associated with coronary artery bypass grafting] was observed between patients in the low- risk class and those in the high-risk class (p[trend]<0.001).” The authors validated their findings with data from the ART- PCI trial, which investigated the impact of high on-treatment platelet reactivity on clinical outcomes in PCI patients. Mrdovic et al wrote that the implica- tions of their risk model were that it could be used direct treatment. They stated: “Patients in the low-risk class might be treated via femoral approach, using a bare metal stent or drug-eluting stent and optimal doses of antiplatelet drugs. In contrast, patients in the high- risk class should be treated preferably with bare metal stents and/or a radial approach, which appeared to be as- sociated with a significant reduction in vascular complications compared with the femoral approach.” They added that, in high-risk patients, excessive does of antithrombotic drugs should be avoided as should the potent thienopyridines.
Non-access site bleeding is a stronger predictor of mortality than access site bleeding
Gjin Ndrepepa (Deutsches Herzzentrum München, Technische Universität, Munchen, Germany) and others reported in Circulation: Cardiovascular Interventions that non-access site bleeding after percutaneous coronary intervention (PCI) is a stronger predictor of mortality than is access site bleeding and it improves the discriminatory power of models for mortality prediction
drepepa et al commented that “little is known” about the relationship between site of bleeding and clinical outcome and that the purpose of their study was to, using the Bleeding Academic Research Consortium (BARC) criteria, evaluate bleeding events after PCI with three objectives. These objectives were assessing the association between access site and non-access site bleeding within the first 30 days after PCI and mortality; investigating factors associated with access site and non-access site bleeding; and investigating whether bleeding events of different locations improved the discriminatory power of the multivariate models on mortality prediction.
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In a pooled patient-level analysis of 14,180 patients from seven randomised controlled trials, the authors found that 1,510 patients had a bleeding event within 30 days of undergoing a PCI procedure. Of these, 905 had access site bleeding and 605 had non-access bleeding. Ndrepepa et al noted that 120 patients with non-access site bleeding also had access site bleeding.
They reported: “Access site and non-access site bleeding were each independently associated with an increased risk of one-year mortality, showing a 1.72- and 2.78-fold increase in the adjusted risk for mortality, respectively, compared with patients who
did not bleed. The adjusted risk of mortality associated with non-access site bleeding was 62% higher than the adjusted risk for mortality associated with access site bleeding.” The authors added that the inclusion of access site bleeding into a mortality prediction model did not significantly improve the discriminatory power of the model (p=0.084). However, they said that the inclusion of non-access site bleeding into the model was associated “with a significant increase of the discriminatory power of the model on predictor of mortality compared with the model without bleeding (p=0.031).”
Another important finding in the study, Ndrepepa et Adnan Kastrati
al stated, was that patients with non-access site bleeding had a “more adverse cardiovascular risk profile” than the patients with access site bleeding even though they shared similar predisposing factors. Study author Adnan Kastrati, Deutsches Herzzentrum München, Technische Universität, Munchen, Germany, told Cardiovascular News: “Although radial access may reduce the risk of access site bleeding, reduction of the prognostically more relevant form of bleeding, non-access site bleeding, may require a broader use of antithrombotic drugs with bleeding reducing properties such as bivalirudin. Special medical attention should be reserved to certain categories of patients with excess risk of non-access site bleeding such as older patients, women, patients with small body mass index and those with chronic kidney disease.”
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