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Multicenter Study
. 2010 Mar;31(6):667-75.
doi: 10.1093/eurheartj/ehp499. Epub 2009 Dec 8.

Has the frequency of bleeding changed over time for patients presenting with an acute coronary syndrome? The global registry of acute coronary events

Keith A A Fox  1 , Kathryn Carruthers, Ph Gabriel Steg, Alvaro Avezum, Christopher B Granger, Gilles Montalescot, Shaun G Goodman, Joel M Gore, Ann L Quill, Kim A Eagle; GRACE Investigators
Affiliations
Multicenter Study

Has the frequency of bleeding changed over time for patients presenting with an acute coronary syndrome? The global registry of acute coronary events

Keith A A Fox et al. Eur Heart J. 2010 Mar.

Abstract

Aims: To determine whether changes in practice, over time, are associated with altered rates of major bleeding in acute coronary syndromes (ACS).

Methods and results: Patients from the Global Registry of Acute Coronary Events were enrolled between 2000 and 2007. The main outcome measures were frequency of major bleeding, including haemorrhagic stroke, over time, after adjustment for patient characteristics, and impact of major bleeding on death and myocardial infarction. Of the 50 947 patients, 2.3% sustained a major bleed; almost half of these presented with ST-elevation ACS (44%, 513). Despite changes in antithrombotic therapy (increasing use of low molecular weight heparin, P < 0.0001), thienopyridines (P < 0.0001), and percutaneous coronary interventions (P < 0.0001), frequency of major bleeding for all ACS patients decreased (2.6 to 1.8%; P < 0.0001). Most decline was seen in ST-elevation ACS (2.9 to 2.1%, P = 0.02). The overall decline remained after adjustment for patient characteristics and treatments (P = 0.002, hazard ratio 0.94 per year, 95% confidence interval 0.91-0.98). Hospital characteristics were an independent predictor of bleeding (P < 0.0001). Patients who experienced major bleeding were at increased risk of death within 30 days from admission, even after adjustment for baseline variables.

Conclusion: Despite increasing use of more intensive therapies, there was a decline in the rate of major bleeding associated with changes in clinical practice. However, individual hospital characteristics remain an important determinant of the frequency of major bleeding.

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Figures

Figure 1
Figure 1
Temporal trends in cardiac procedures in all patients with an ACS, in patients with ST-segment elevation, ST-segment depression, or no ST shift, and fibrinolysis in patients with ST-elevation ACS.
Figure 2
Figure 2
Kaplan–Meier plot of major bleeds and/or haemorrhagic stroke and/or subdural haematoma from hospital admission up to 15 days in patients with ST-segment elevation, ST-segment depression, or neither.
Figure 3
Figure 3
Temporal trends in the rates of major bleeding and/or haemorrhagic stroke and/or subdural haematoma, in patients with ST-segment elevation, ST-segment depression, or neither.
Figure 4
Figure 4
Hospitals divided into quintiles according to percentage of in-hospital bleeds (figure; data show medians, minimum and maximum values; 17 or 18 hospitals per quintile) and in-hospital death (table). All data are derived from hospitals that provided bleeding status in ≥100 patients.
Figure 5
Figure 5
Risk of 30-day death (2000–2007; n = 45 406 patients with an acute coronary syndrome) and 30-day myocardial (re)infarction (2003–2007; n = 26 126), adjusted for GRACE risk variables and treatment interventions (catheterization, PCI, fibrinolytics): patients with vs. without a major bleed and/or haemorrhagic stroke and/or subdural haematoma.
See this image and copyright information in PMC

Comment in

References

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