Association of spontaneous bleeding and myocardial infarction with long-term mortality after percutaneous coronary intervention

Platelet inhibition after percutaneous coronary intervention (PCI) reduces the risk of myocardial infarction (MI) but increases the risk of bleeding. MIs and bleeds during the index hospitalization for PCI are known to negatively affect long-term outcomes. The impact of spontaneous bleeding occurrin...

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Vydáno v:	Journal of the American College of Cardiology Ročník 65; číslo 14; s. 1411
Hlavní autoři:	Kazi, Dhruv S, Leong, Thomas K, Chang, Tara I, Solomon, Matthew D, Hlatky, Mark A, Go, Alan S
Médium:	Journal Article
Jazyk:	angličtina
Vydáno:	United States 14.04.2015
Témata:	Aged Aged, 80 and over Cohort Studies Female Follow-Up Studies Humans Longitudinal Studies Male Middle Aged Mortality - trends Myocardial Infarction - diagnosis Myocardial Infarction - mortality Percutaneous Coronary Intervention - mortality Postoperative Hemorrhage - diagnosis Postoperative Hemorrhage - mortality Retrospective Studies health outcomes health services research antiplatelet agents hemorrhage personalized medicine
ISSN:	1558-3597, 1558-3597
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Abstract	Platelet inhibition after percutaneous coronary intervention (PCI) reduces the risk of myocardial infarction (MI) but increases the risk of bleeding. MIs and bleeds during the index hospitalization for PCI are known to negatively affect long-term outcomes. The impact of spontaneous bleeding occurring after discharge on long-term mortality is unknown. This study sought to examine, in a real-world cohort, the association between spontaneous major bleeding or MI after PCI and long-term mortality. We conducted a retrospective cohort study of patients ≥30 years of age who underwent a PCI between 1996 and 2008 in an integrated healthcare delivery system. We used extended Cox regression to examine the associations of spontaneous bleeding and MI with all-cause mortality, after adjustment for time-updated demographics, comorbidities, periprocedural events, and longitudinal medication exposure. Among 32,906 patients who had a PCI and survived the index hospitalization, 530 had bleeds and 991 had MIs between 7 and 365 days post-discharge. There were 4,048 deaths over a mean follow-up of 4.42 years. The crude annual death rate after a spontaneous bleed (9.5%) or MI (7.6%) was higher than among patients who experienced neither event (2.6%). Bleeding was associated with an increased rate of death (adjusted hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.30 to 2.00), similar to that after an MI (HR: 1.91; 95% CI: 1.62 to 2.25). The association of bleeding with death remained significant after additional adjustment for the longitudinal use of antiplatelet agents. Spontaneous bleeding after a PCI was independently associated with higher long-term mortality, and conveyed a risk comparable to that of an MI during follow-up. This tradeoff between efficacy and safety bolsters the argument for personalizing antiplatelet therapy after PCI on the basis of the patient's long-term risk of both thrombotic and bleeding events.
AbstractList	Platelet inhibition after percutaneous coronary intervention (PCI) reduces the risk of myocardial infarction (MI) but increases the risk of bleeding. MIs and bleeds during the index hospitalization for PCI are known to negatively affect long-term outcomes. The impact of spontaneous bleeding occurring after discharge on long-term mortality is unknown.BACKGROUNDPlatelet inhibition after percutaneous coronary intervention (PCI) reduces the risk of myocardial infarction (MI) but increases the risk of bleeding. MIs and bleeds during the index hospitalization for PCI are known to negatively affect long-term outcomes. The impact of spontaneous bleeding occurring after discharge on long-term mortality is unknown.This study sought to examine, in a real-world cohort, the association between spontaneous major bleeding or MI after PCI and long-term mortality.OBJECTIVESThis study sought to examine, in a real-world cohort, the association between spontaneous major bleeding or MI after PCI and long-term mortality.We conducted a retrospective cohort study of patients ≥30 years of age who underwent a PCI between 1996 and 2008 in an integrated healthcare delivery system. We used extended Cox regression to examine the associations of spontaneous bleeding and MI with all-cause mortality, after adjustment for time-updated demographics, comorbidities, periprocedural events, and longitudinal medication exposure.METHODSWe conducted a retrospective cohort study of patients ≥30 years of age who underwent a PCI between 1996 and 2008 in an integrated healthcare delivery system. We used extended Cox regression to examine the associations of spontaneous bleeding and MI with all-cause mortality, after adjustment for time-updated demographics, comorbidities, periprocedural events, and longitudinal medication exposure.Among 32,906 patients who had a PCI and survived the index hospitalization, 530 had bleeds and 991 had MIs between 7 and 365 days post-discharge. There were 4,048 deaths over a mean follow-up of 4.42 years. The crude annual death rate after a spontaneous bleed (9.5%) or MI (7.6%) was higher than among patients who experienced neither event (2.6%). Bleeding was associated with an increased rate of death (adjusted hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.30 to 2.00), similar to that after an MI (HR: 1.91; 95% CI: 1.62 to 2.25). The association of bleeding with death remained significant after additional adjustment for the longitudinal use of antiplatelet agents.RESULTSAmong 32,906 patients who had a PCI and survived the index hospitalization, 530 had bleeds and 991 had MIs between 7 and 365 days post-discharge. There were 4,048 deaths over a mean follow-up of 4.42 years. The crude annual death rate after a spontaneous bleed (9.5%) or MI (7.6%) was higher than among patients who experienced neither event (2.6%). Bleeding was associated with an increased rate of death (adjusted hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.30 to 2.00), similar to that after an MI (HR: 1.91; 95% CI: 1.62 to 2.25). The association of bleeding with death remained significant after additional adjustment for the longitudinal use of antiplatelet agents.Spontaneous bleeding after a PCI was independently associated with higher long-term mortality, and conveyed a risk comparable to that of an MI during follow-up. This tradeoff between efficacy and safety bolsters the argument for personalizing antiplatelet therapy after PCI on the basis of the patient's long-term risk of both thrombotic and bleeding events.CONCLUSIONSSpontaneous bleeding after a PCI was independently associated with higher long-term mortality, and conveyed a risk comparable to that of an MI during follow-up. This tradeoff between efficacy and safety bolsters the argument for personalizing antiplatelet therapy after PCI on the basis of the patient's long-term risk of both thrombotic and bleeding events. Platelet inhibition after percutaneous coronary intervention (PCI) reduces the risk of myocardial infarction (MI) but increases the risk of bleeding. MIs and bleeds during the index hospitalization for PCI are known to negatively affect long-term outcomes. The impact of spontaneous bleeding occurring after discharge on long-term mortality is unknown. This study sought to examine, in a real-world cohort, the association between spontaneous major bleeding or MI after PCI and long-term mortality. We conducted a retrospective cohort study of patients ≥30 years of age who underwent a PCI between 1996 and 2008 in an integrated healthcare delivery system. We used extended Cox regression to examine the associations of spontaneous bleeding and MI with all-cause mortality, after adjustment for time-updated demographics, comorbidities, periprocedural events, and longitudinal medication exposure. Among 32,906 patients who had a PCI and survived the index hospitalization, 530 had bleeds and 991 had MIs between 7 and 365 days post-discharge. There were 4,048 deaths over a mean follow-up of 4.42 years. The crude annual death rate after a spontaneous bleed (9.5%) or MI (7.6%) was higher than among patients who experienced neither event (2.6%). Bleeding was associated with an increased rate of death (adjusted hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.30 to 2.00), similar to that after an MI (HR: 1.91; 95% CI: 1.62 to 2.25). The association of bleeding with death remained significant after additional adjustment for the longitudinal use of antiplatelet agents. Spontaneous bleeding after a PCI was independently associated with higher long-term mortality, and conveyed a risk comparable to that of an MI during follow-up. This tradeoff between efficacy and safety bolsters the argument for personalizing antiplatelet therapy after PCI on the basis of the patient's long-term risk of both thrombotic and bleeding events.
Author	Hlatky, Mark A Kazi, Dhruv S Chang, Tara I Leong, Thomas K Go, Alan S Solomon, Matthew D
Author_xml	– sequence: 1 givenname: Dhruv S surname: Kazi fullname: Kazi, Dhruv S email: kazi@ucsf.edu organization: Division of Cardiology, San Francisco General Hospital, San Francisco, California; Department of Medicine (Cardiology), University of California San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California. Electronic address: kazi@ucsf.edu – sequence: 2 givenname: Thomas K surname: Leong fullname: Leong, Thomas K organization: Division of Research, Kaiser Permanente Northern California, Oakland, California – sequence: 3 givenname: Tara I surname: Chang fullname: Chang, Tara I organization: Department of Medicine, Stanford University, Stanford, California – sequence: 4 givenname: Matthew D surname: Solomon fullname: Solomon, Matthew D organization: Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Medicine, Stanford University, Stanford, California – sequence: 5 givenname: Mark A surname: Hlatky fullname: Hlatky, Mark A organization: Department of Medicine, Stanford University, Stanford, California; Department of Health Research and Policy, Stanford University, Stanford, California – sequence: 6 givenname: Alan S surname: Go fullname: Go, Alan S organization: Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Health Research and Policy, Stanford University, Stanford, California
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SubjectTerms	Aged Aged, 80 and over Cohort Studies Female Follow-Up Studies Humans Longitudinal Studies Male Middle Aged Mortality - trends Myocardial Infarction - diagnosis Myocardial Infarction - mortality Percutaneous Coronary Intervention - mortality Postoperative Hemorrhage - diagnosis Postoperative Hemorrhage - mortality Retrospective Studies
Title	Association of spontaneous bleeding and myocardial infarction with long-term mortality after percutaneous coronary intervention
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