4175Differential prognostic impact in mortality of myocardial infarction compared with bleeding severity in contemporary acute coronary syndrome patients

Introduction and objectives: The impact on mortality of myocardial infarction (MI) compared to specific degree of bleeding severity occurring after discharge for acute coronary syndrome, is poorly characterized. Defining this relationship may help achieving a favorable therapeutic benefit-risk balance. Methods: Using Cox-based shared frailty models, we assessed the relationship between mortality and postdischarge MI and with bleeding severity – graded according to Bleeding Academic Research Consortium (BARC) – in 4229 acute coronary syndrome patients undergoing in-hospital coronary arteriography between January 2012 and December 2015. Results: Both MI (HR, 5.8; 95% CI, 3.7–9.8) and bleeding (HR, 5.1; 95% CI, 3.6–7.7) were associated with mortality. Myocardial infarction had higher impact on mortality than BARC type 2 and 3a bleedings: (RRr, 3.8 and 1.9; (P<0.05), respectively, but was equivalent to BARC type 3b (RRr, 0.9; P=0.88). Mortality risk after MI was significantly lower than following BARC type 3c bleeding (RRr, 0.25; P<0.001) (Figure 1). A MI event occurring while patients were on dual antiplatelet therapy (DAPT) engendered a higher mortality risk (HR, 2.9; 95% CI, 1.8–4.5) compared with patients off-DAPT (HR, 1.5; 95% CI, 0.7–3.4) at the time of MI. However, a bleeding event while patients were on-DAPT was related to lower mortality risk (HR, 1.6; 95% CI, 1.1–2.6) compared with off-DAPT patients (HR, 3.2; 95% CI, 1.7–5.8).