Predictors and impact of bleeding complications in percutaneous coronary intervention, acute coronary syndromes, and ST-segment elevation myocardial infarction

Abstract

Although the use of oral and intravenous antiplatelet and antithrombin therapy in the acute and chronic settings of percutaneous coronary intervention (PCI), acute coronary syndromes (ACS), and ST-segment elevation myocardial infarction (STEMI) effectively reduce ischemic event rates, they are mechanistically and inextricably linked to an increased risk of bleeding. As longer courses of more complex, potent regimens are used, increased efficacy may be offset by increases in major, minor, and nuisance bleeding, both in the inpatient and outpatient setting. Consequently, more frequent challenges with cessation of and compliance with antithrombotic therapy are to be expected. Extensive data indicate that bleeding complications (1) occur with relative frequency; (2) independently affect adverse outcomes, such as mortality; (3) carry similar importance in adversely influencing mortality as ischemic events; (4) can be predicted by recognizing patient, presentation, treatment, and procedural risk factors for bleeding; and (5) can be modified by pharmacologic and nonpharmacologic means. Factors associated with increased bleeding risk include: (1) patient characteristics (including advanced age, female sex, hypertension, renal disease, anemia, previous history of bleeding, and perhaps diabetes mellitus), (2) clinical presentation (bleeding rates appears lowest for PCI, higher for ACS, and highest for STEMI), (3) abnormalities of cardiac biomarkers and/or electrocardiography, (4) invasive procedures (such as cardiac catheterization and PCI), and (5) the choice of antiplatelet and antithrombin therapy. In the context of a bleeding assessment, evidence-based decision making should always result in the selection of appropriate pharmacologic and nonpharmacologic strategies, invasive or conservative management plans, and stent types (bare metal vs drug-eluting) that will offer the best balance of benefit and risk with the goal of optimizing outcomes.