Post-Discharge Bleeding and Mortality Following Acute Coronary Syndromes With or Without PCI

• Published in: Journal of the American College of Cardiology Vol. 76; no. 2; pp. 162 - 171
• Main Authors: Marquis-Gravel, Guillaume, Dalgaard, Frederik, Jones, Aaron D., Lokhnygina, Yuliya, James, Stefan K., Harrington, Robert A., Wallentin, Lars, Steg, Philippe Gabriel, Lopes, Renato D., Storey, Robert F., Goodman, Shaun G., Mahaffey, Kenneth W., Tricoci, Pierluigi, White, Harvey D., Armstrong, Paul W., Ohman, E. Magnus, Alexander, John H., Roe, Matthew T.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 14.07.2020
• Subjects: acute coronary syndrome; Acute Coronary Syndrome - therapy; Aged; bleeding; Canada - epidemiology; Cardiovascular; Female; Hemorrhage - epidemiology; Hemorrhage - etiology; Humans; Incidence; Male; Middle Aged; mortality; Patient Discharge; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors - therapeutic use; randomized trial; Survival Rate - trends; Treatment Outcome; United Kingdom - epidemiology; United States - epidemiology; Canada; United States; United Kingdom; ACS; percutaneous coronary intervention; acute coronary syndrome; bleeding; randomized trial; CI; PCI; mortality; HR; CABG; MI; DAPT; myocardial infarction; dual antiplatelet therapy; hazard ratio; confidence interval; acute coronary syndrome(s); coronary artery bypass grafting
• ISSN: 0735-1097; 1558-3597; 1558-3597
• DOI: 10.1016/j.jacc.2020.05.031

The long-term prognostic impact of post-discharge bleeding in the unique population of patients with acute coronary syndrome (ACS) treated without percutaneous coronary intervention (PCI) remains unexplored. The aim of this study was to assess the association between post-discharge bleeding and subsequent mortality after ACS according to index strategy (PCI or no PCI) and to contrast with the association between post-discharge myocardial infarction (MI) and subsequent mortality. In a harmonized dataset of 4 multicenter randomized trials (APPRAISE-2 [Apixaban for Prevention of Acute Ischemic Events-2], PLATO [Study of Platelet Inhibition and Patient Outcomes], TRACER [Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome], and TRILOGY ACS [Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes]), the association between post-discharge noncoronary artery bypass graft–related GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) moderate, severe, or life-threatening bleeding (landmark 7 days post-ACS) and subsequent all-cause mortality was evaluated in a time-updated Cox proportional hazards analysis. Interaction with index treatment strategy was assessed. Results were contrasted with risk for mortality following post-discharge MI. Among 45,011 participants, 1,133 experienced post-discharge bleeding events (2.6 per 100 patient-years), and 2,149 died during follow-up. The risk for mortality was significantly higher <30 days (adjusted hazard ratio: 15.7; 95% confidence interval: 12.3 to 20.0) and 30 days to 12 months (adjusted hazard ratio: 2.7; 95% confidence interval: 2.1 to 3.4) after bleeding, and this association was consistent in participants treated with or without PCI for their index ACS (p for interaction = 0.240). The time-related association between post-discharge bleeding and mortality was similar to the association between MI and subsequent mortality in participants treated with and without PCI (p for interaction = 0.696). Post-discharge bleeding after ACS is associated with a similar increase in subsequent all-cause mortality in participants treated with or without PCI and has an equivalent prognostic impact as post-discharge MI. [Display omitted]