Incidence, Prognostic Impact, and Influence of Antithrombotic Therapy on Access and Nonaccess Site Bleeding in Percutaneous Coronary Intervention

Radboud University Medical Centre, Nijmegen, the Netherlands.
JACC. Cardiovascular Interventions (Impact Factor: 7.35). 02/2011; 4(2):191-7. DOI: 10.1016/j.jcin.2010.10.011
Source: PubMed


The aim of this study was to evaluate the relative frequency of access and nonaccess site bleeding, the association of these events with 1-year mortality, and the impact of randomized antithrombotic therapy.
Post-percutaneous coronary intervention (PCI) bleeding has been strongly associated with subsequent mortality. The extent to which access versus nonaccess site bleeding contributes to this poor prognosis and the role of antithrombotic therapies remains poorly understood.
The incidence and impact of Thrombolysis In Myocardial Infarction (TIMI) major/minor 30-day bleeding and randomized antithrombotic therapy were examined in a combined dataset from the REPLACE-2 (Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events), Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY), and HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trials in 17,393 PCI patients.
The TIMI major/minor bleeding occurred in 5.3% of patients, 61.4% of which (3.3%) were nonaccess site bleeds. After multivariable adjustment, TIMI bleeding was associated with an increased risk of 1-year mortality (hazard ratio [HR]: 3.17, 95% confidence interval [CI]: 2.51 to 4.00, p < 0.0001). The HR of a nonaccess site bleed was approximately 2-fold that of an access site bleed: HR: 3.94, 95% CI: 3.07 to 5.15, p < 0.0001 versus HR: 1.82, 95% CI: 1.17 to 2.83, p = 0.008, respectively. Randomization to bivalirudin versus heparin + a glycoprotein IIb/IIIa inhibitor resulted in 38% and 43% relative reductions in TIMI major/minor and TIMI major bleeding, respectively (p < 0.0001 for both), with significant reductions in both access and nonaccess site bleeding.
Nonaccess site bleeding after PCI is common, representing approximately two-thirds of all TIMI bleeding events, and is associated with a 4-fold increase in 1-year mortality. Use of bivalirudin rather than heparin + a glycoprotein IIb/IIIa inhibitor significantly decreases both nonaccess site as well as access site bleeding events by approximately 40%.

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Available from: Philippe Gabriel Steg, Jan 27, 2014
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    • "According to the Global Registry of Acute Coronary Events (GRACE), the most frequent bleeding sites were gastrointestinal (31.5%) and those related to vascular access (23.8%), with the latter being more prevalent among patients submitted to invasive strategies [11]. In a joint analysis of 17,393 acute coronary syndrome (ACS) patients submitted to percutaneous coronary intervention (PCI) and included in the studies Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE) - 2, ACUITY and Harmonizing Outcomes with RevascularIZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI), the bleeding prevalence by Thrombosis in Myocardial Infarction (TIMI) criteria was 5.3%, of which 2.1% (38.6%) were related to vascular access [14]. "
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    • "Recent studies point out that bivalirudin compared to heparin + GPIIb/IIIa inhibitors is associated with an approximately 40% reduction in both non-access site as well as access site bleedings, preserving similar antithrombotic protection if an adequate antiplatelet pre-treatment is provided.4,13,14 "
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