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Incidence, Predictors, and Impact of Post-Discharge Bleeding After Percutaneous Coronary Intervention
Philippe Généreux1, Gennaro Giustino2, Bernhard Witzenbichler3
1Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York; Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada.
Insights
Post-discharge bleeding (PDB) after percutaneous coronary intervention with drug-eluting stents is common and significantly increases mortality risk. Reducing PDB after PCI with DES is crucial for improving patient outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- The incidence, predictors, and prognostic impact of post-discharge bleeding (PDB) following percutaneous coronary intervention (PCI) with drug-eluting stents (DES) remain incompletely understood.
- Understanding PDB is critical for optimizing patient management after PCI.
Purpose of the Study:
- To characterize the incidence, predictors, and clinical consequences of PDB in patients undergoing PCI with DES.
- To evaluate the association between PDB and subsequent all-cause mortality.
Main Methods:
- Prospective analysis of the ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) study.
- Inclusion of 8,582 "all-comers" who underwent successful PCI with DES.
- Assessment of clinically relevant bleeding events and all-cause mortality within 2 years post-discharge using time-adjusted Cox proportional hazards regression.
Main Results:
- The incidence of PDB was 6.2% (535/8,577) occurring at a median of 300 days post-discharge, with gastrointestinal bleeding being the most frequent source (61.7%).
- Predictors of PDB included older age, lower hemoglobin, reduced clopidogrel platelet reactivity, and oral anticoagulation use.
- PDB was strongly associated with a 5-fold increased risk of 2-year all-cause mortality (HR: 5.03; p < 0.0001), an effect larger than that of post-discharge myocardial infarction.
Conclusions:
- Post-discharge bleeding is a significant and not uncommon complication after successful PCI with DES in an unselected population.
- PDB carries a substantial prognostic burden, independently associated with increased long-term mortality.
- Strategies aimed at mitigating PDB may enhance the prognosis for patients treated with DES.
Background:
The incidence, predictors, and prognostic impact of post-discharge bleeding (PDB) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation are unclear.
Objectives:
This study sought to characterize the determinants and consequences of PDB after PCI.
Methods:
The prospective ADAPT-DES (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents) study was used to determine the incidence and predictors of clinically relevant bleeding events occurring within 2 years after hospital discharge. The effect of PDB on subsequent 2-year all-cause mortality was estimated by time-adjusted Cox proportional hazards regression.
Results:
Among 8,582 "all-comers" who underwent successful PCI with DES in the ADAPT-DES study, PDB occurred in 535 of 8,577 hospital survivors (6.2%) at a median time of 300 days (interquartile range: 130 to 509 days) post-discharge. Gastrointestinal bleeding (61.7%) was the most frequent source of PDB. Predictors of PDB included older age, lower baseline hemoglobin, lower platelet reactivity on clopidogrel, and use of chronic oral anticoagulation therapy. PDB was associated with higher crude rates of all-cause mortality (13.0% vs. 3.2%; p < 0.0001). Following multivariable adjustment, PDB was strongly associated with 2-year mortality (hazard ratio [HR]: 5.03; p < 0.0001), with an effect size greater than that of post-discharge myocardial infarction (PDMI) (HR: 1.92; p = 0.009).
Conclusions:
After successful PCI with DES in an unrestricted patient population, PDB is not uncommon and has a strong relationship with subsequent all-cause mortality, greater that that associated with PDMI. Efforts to reduce PDB may further improve prognosis after successful DES implantation. (Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents [ADAPT-DES]; NCT00638794).
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