Key result
Major bleeding in ACS declined ~6% per year despite increasing use of intensive therapies.
Why the study?
Changes in clinical practice over time may be associated with altered rates of major bleeding in patients with acute coronary syndromes, but this relationship was not well defined.
Cohort (n=50,947)
Yes
Hazard Ratio: 0.94 (95% CI 0.91–0.98)
Absolute Event Rate: 1.8% vs 2.6%
p-value: p=0.002
Declining ACS bleeding rates despite intensified therapy are reassuring; cohort data leaves open causality and generalizability.
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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Fox et al. (2009) conducted a cohort in Acute Coronary Syndrome (n=50,947). Admission year (temporal trends 2000-2007) vs. Earlier admission years was evaluated on Frequency of major in-hospital bleeding over time (per year) (HR 0.94, 95% CI 0.91-0.98, p=0.002). The frequency of major bleeding in acute coronary syndrome patients decreased from 2.6% in 2000 to 1.8% in 2007, showing an adjusted HR of 0.94 per year despite increased intensive therapy use.
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