Key result
Modern bleeding avoidance strategies linked to ~20% lower post-PCI bleeding, driven by bivalirudin use.
Why the study?
The impact of bleeding avoidance strategies on post-PCI bleeding rates over time was unknown.
Do temporal changes in bleeding avoidance strategies (vascular access and antithrombotic therapies) reduce in-hospital major bleeding in patients undergoing PCI?
Observational (n=1,703,259)
Yes
Do temporal changes in bleeding avoidance strategies (vascular access and antithrombotic therapies) reduce in-hospital major bleeding in patients undergoing PCI?
A nearly 20% reduction in post-PCI bleeding from 2005 to 2009 was largely driven by temporal shifts in antithrombotic strategies, such as increased bivalirudin use and decreased heparin plus glycoprotein IIb/IIIa inhibitor use.
Answers are grounded in this paper and cite their sources.
Bleeding reductions were associated with antithrombotic shifts; extends temporal trends but leaves causal roles open for prospective confirmation.
Objectives The purpose of this study was to examine temporal trends in post-percutaneous coronary intervention (PCI) bleeding among patients with elective PCI, unstable angina (UA)/non–ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Background The impact of bleeding avoidance strategies on post-PCI bleeding rates over time is unknown. Methods Using the CathPCI Registry, we examined temporal trends in post-PCI bleeding from 2005 to 2009 among patients with elective PCI (n = 599,524), UA/NSTEMI (n = 836,103), and STEMI (n = 267,632). We quantified the linear time trend in bleeding using 3 sequential logistic regression models: 1) clinical factors; 2) clinical + vascular access strategies (femoral vs. radial, use of closure devices); and 3) clinical, vascular strategies + antithrombotic treatments (anticoagulant ± glycoprotein IIb/IIIa inhibitor [GPI]). Changes in the odds ratio for time trend in bleeding were compared using bootstrapping and converted to risk ratio. Results An approximate 20% reduction in post-PCI bleeding was seen (elective PCI: 1.4% to 1.1%; UA/NSTEMI: 2.3% to 1.8; STEMI: 4.9% to 4.5%). Radial approach remained low (<3%), and closure device use increased marginally from 44% to 49%. Bivalirudin use increased (17% to 30%), whereas any heparin + GPI decreased (41% to 28%). There was a significant 6% to 8% per year reduction in annual bleeding risk in UA/NSTEMI and elective PCI, but not in STEMI. Antithrombotic strategies were associated with roughly half of the reduction in annual bleeding risk: change in risk ratio from 7.5% to 4% for elective PCI, and 5.7% to 2.8% for UA/NSTEMI (both p <0.001). Conclusions The nearly 20% reduction in post-PCI bleeding over time was largely due to temporal changes in antithrombotic strategies. Further reductions in bleeding complications may be possible as bleeding avoidance strategies evolve, especially in STEMI.
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Subherwal et al. (2012) conducted an observational in Patients undergoing percutaneous coronary intervention (n=1,703,259). Temporal changes in bleeding avoidance strategies (antithrombotic and vascular access) vs. Earlier time period (2005) was evaluated on In-hospital major bleeding (elective PCI subgroup) (OR 0.919 (per year reduction), 95% CI 0.895-0.945, p=<0.001). Post-PCI bleeding decreased by approximately 20% from 2005 to 2009, largely associated with temporal changes in antithrombotic strategies such as increased bivalirudin use.
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