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Association between use of bleeding avoidance strategies and risk of periprocedural bleeding among patients
Steven P Marso1, Amit P Amin, John A House
1Saint Luke's Mid America Heart Institute, University of Missouri Kansas City, 4401 Wornall Rd, Kansas City, MO 64111, USA. smarso@saint-lukes.org
Insights
Bleeding avoidance strategies like vascular closure devices and bivalirudin significantly reduce bleeding after percutaneous coronary intervention (PCI), especially in high-risk patients. However, these effective strategies are underutilized in those who would benefit most.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Patient Safety
Background:
- Bleeding complications following percutaneous coronary intervention (PCI) are linked to adverse patient outcomes.
- The effectiveness of bleeding avoidance strategies based on preprocedural bleeding risk is not well understood.
Purpose of the Study:
- To evaluate the utilization of vascular closure devices and bivalirudin for bleeding avoidance.
- To determine the association between these strategies and post-PCI bleeding rates in a national population.
Main Methods:
- Analysis of 1,522,935 PCI procedures from the NCDR CathPCI Registry (2004-2008).
- Assessment of periprocedural bleeding rates associated with manual compression, vascular closure devices, bivalirudin, or both.
- Evaluation of bleeding rates across different preprocedural bleeding risk strata.
Main Results:
- Overall bleeding rate was 2%.
- Use of vascular closure devices and/or bivalirudin was associated with significantly lower bleeding rates compared to manual compression (0.9% vs 2.8%).
- Higher bleeding rates were observed in high-risk patients, but combined strategies showed the greatest benefit (2.3% bleeding).
- Bleeding avoidance strategies were least utilized in high-risk patients.
Conclusions:
- Vascular closure devices and bivalirudin are associated with reduced bleeding post-PCI.
- These beneficial strategies are underused in patients at the highest risk of bleeding.
- Optimizing the use of these strategies may improve patient safety in PCI.
Context:
Bleeding complications with percutaneous coronary intervention (PCI) are associated with adverse patient outcomes. The association between the use of bleeding avoidance strategies and post-PCI bleeding as a function of a patient's preprocedural risk of bleeding is unknown.
Objective:
To describe the use of 2 bleeding avoidance strategies, vascular closure devices and bivalirudin, and associated post-PCI bleeding rates in a nationally representative PCI population.
Design, Setting, And Patients:
Analysis of data from 1,522,935 patients undergoing PCI procedures performed at 955 US hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry from January 1, 2004, through September 30, 2008.
Main Outcome Measure:
Periprocedural bleeding.
Results:
Bleeding occurred in 30,654 patients (2%). Manual compression, vascular closure devices, bivalirudin, or vascular closure devices plus bivalirudin were used in 35%, 24%, 23%, and 18% of patients, respectively. Bleeding events were reported in 2.8% of patients who received manual compression, compared with 2.1%, 1.6%, and 0.9% of patients receiving vascular closure devices, bivalirudin, and both strategies, respectively (P < .001). Bleeding rates differed by preprocedural risk assessed with the NCDR bleeding risk model (low risk, 0.72%; intermediate risk, 1.73%; high risk, 4.69%). In high-risk patients, use of both strategies was associated with lower bleeding rates (manual compression, 6.1%; vascular closure devices, 4.6%; bivalirudin, 3.8%; vascular closure devices plus bivalirudin, 2.3%; P < .001). This association persisted following adjustment using a propensity-matched and site-controlled model. Use of both strategies was used least often in high-risk patients (14.4% vs 21.0% in low-risk patients, P < .001).
Conclusions:
In a large national PCI registry, vascular closure devices and bivalirudin were associated with significantly lower bleeding rates, particularly among patients at greatest risk for bleeding. However, these strategies were less often used among higher-risk patients.
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