medwireNews: Treatment with antithrombotic drugs before coronary angiography is associated with excess bleeding in patients with non–ST-segment elevation acute coronary syndromes, study results suggest.
These findings suggest that antithrombotic drugs “should be used judiciously in patients awaiting angiography and that earlier angiography could improve the benefit of angiographic interventions in proportion,” write study authors Philippe Généreux (Cardiovascular Research Foundation, New York, USA) and colleagues.
In a post-hoc analysis of data from the ACUITY trial, the authors found that 2.0% of 13,726 patients experienced bleeding prior to angiography, 0.4% of whom had major bleeding. Bleeding events were “considerably more common” than reinfarction, which was experienced by 0.3% of participants, say the authors in the Journal of the American College of Cardiology.
Patients who experienced bleeding were more likely to have received low molecular weight heparin and less likely to have received unfractionated heparin at baseline than those who did not bleed, at 42.9% versus 25.2% and 25.5% versus 41.2%, respectively.
Additionally, those who bled were more likely to have received glycoprotein IIb/IIIa inhibitors and less likely to have received bivalirudin than those who did not bleed (63.6 vs 32.8% and 55.6 vs 64.9%, respectively).
After adjustment for factors including age, gender, diabetes, smoking, and prior percutaneous coronary intervention, the bleeding risk was higher among patients treated with multiple antithrombotic medications, with a hazard ratio (HR) of 1.33 per additional drug. Age and renal insufficiency were also identified as independent predictors of bleeding before coronary angiography.
Bleeding while waiting for coronary angiography was associated with significantly increased mortality risk; a total of 8.5% of patients who bled before angiography died within 1 year, compared with 4.1% of patients who did not(adjusted HR=1.89). The median length of hospital stay was also increased among patients who bled, at 4.8 versus 3.0 days.
In light of the limitations of the analysis, the researchers caution that their findings should be considered “hypothesis generating.” The authors of an accompanying commentary, Michael Lee and Jonathan Gordin (both from David Geffen School of Medicine at UCLA, Los Angeles, California, USA), agree, noting that “causality cannot be determined from a post-hoc analysis.”
However, the study shows that consideration of bleeding risk “must begin the moment patients are admitted, balancing the anti-ischemic benefits of more, stronger antiplatelet and antithrombotic agents against the potential for bleeding complications,” believe the commentators.
And they add: “Bleeding cannot be seen as an isolated incident because its ramifications continue throughout the hospitalization to discharge and beyond, influencing patient management and leading to worse outcomes.”
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