Key result
Post-MI bleeding increased ~88% over two decades, driven by upper GI bleeds, despite declining mortality.
Why the study?
Invasive management and potent antithrombotics reduce ischaemic risk after MI but increase bleeding, with UGIB being common and preventable; trends alongside ischaemic outcomes and treatment paradigms required evaluation.
Over a 20-year period, the adoption of invasive management and potent antithrombotic therapy for MI in Sweden was associated with significantly improved ischemic outcomes and mortality, but at the cost of increased bleeding events, predominantly upper gastrointestinal bleeding.
Bleeding rise with modern MI care despite mortality gains supports prophylaxis trials; leaves open causality and practice change.
Background Invasive management and potent antithrombotic regimens have reduced ischaemic risk after myocardial infarction (MI) but at the cost of an increase in bleeding events, which are associated with poor outcomes. Upper gastrointestinal bleeding (UGIB) is common and amenable to preventive measures. Purpose To analyse UGIB trends in patients with MI in Sweden, alongside ischaemic outcomes and treatment paradigms. Methods Patients with acute MI enrolled in the nationwide SWEDEHEART registry and discharged alive on antithrombotic treatment between 1999 and 2020 were included and evaluated for inpatient bleeding events, all-cause mortality (ACM) and recurrent atherosclerotic cardiovascular disease (rASCVD), defined as coronary heart disease death, non-fatal MI or fatal or non-fatal ischaemic stroke, at one year. By linking to national registries, we identified adverse events using ICD codes, analysing trends in 2-year intervals for the overall cohort and subgroups. Bleeding events were defined by their anatomical origin. Standardised incidence rates for UGIBs were calculated to determine the impact of changes in clinical characteristics, demography, procedures and medical management during the study period. Due to incomplete data for covariates early in the study period, adjusted rates were calculated from 2005-2006 onwards. Results 339 328 cases of MI met the inclusion criteria. The median age was 72 years, 35% were female and 33% had a final diagnosis of STEMI. During the study period bleeding events increased from 2.4% to 4.5%, whereas ACM and rASCVD at 1 year decreased from 12.0% to 7.5% and 20.1% to 9.4%, respectively. The gastrointestinal tract was the most common bleeding source in all time periods (Fig 1), of which a majority were UGIBs. Percutaneous coronary intervention during the index hospitalisation increased from 12.3% to 75.4% and changes in the use of antithrombotic medication at discharge over the study period were substantial (Fig 1). Standardised event rates for UGIB indicate that the change in incidence is largely explained by changes in management (Fig 2). Conclusion Over 20 years bleeding events increased, with GI bleeding being the most common, while ischaemic outcomes after MI improved considerably. These trends align with and may be explained by the adoption of invasive management and potent antithrombotic therapy. Strategies to prevent bleeding events in patients with MI should be evaluated.Trends in bleeding events and therapy Standardised event rates for UGIB at 1y
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Wärme et al. (2025) studied this question. In MI patients, bleeding events doubled from 2.4% to 4.5% over 20 years, with upper GI bleeding most common, while 1-year mortality declined from 12% to 7.5%.
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