Bleeding Events Before Coronary Angiography in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

卷:68

Article

Redfors, Bjorn¹  Kirtane, Ajay J.^1,2  Pocock, Stuart J.³  Ayele, Girma Minalu¹  Deliargyris, Efthymios N.⁴  Mehran, Roxana^1,5  Stone, Gregg W.^1,2  Genereux, Philippe^1,2,6,7 

[1] Cardiovasc Res Fdn, 1700 Broadway,8th Floor, New York, NY 10019 USA

[2] Columbia Univ, Med Ctr, New York Presbyterian Hosp, New York, NY USA

[3] London Sch Hyg & Trop Med, Dept Med Stat, London, England

[4] Medicines Co, Parsippany, NJ USA

[5] Icahn Sch Med Mt Sinai, New York, NY 10029 USA

[6] Hop Sacre Coeur Montreal, Montreal, PQ, Canada

[7] Morristown Med Ctr, Morristown, NJ USA

关键词: antithrombotic drugs;    bleeding;    coronary angiography;    non-ST-elevation acute coronary syndrome;   

DOI  :  10.1016/j.jacc.2016.09.957

来源: Elsevier

【 摘 要 】

BACKGROUND Upstream administration of antithrombotic drugs to patients with non-ST-segment elevation acute coronary syndromes before coronary angiography is a common practice despite an incomplete understanding of the risks and benefits. OBJECTIVES The authors analyzed the incidence of bleeding and ischemic events occurring before angiography and assessed their association with antithrombotic drugs and mortality risk. METHODS All patients from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial with planned angiography after enrollment were included. Bleeding events were classified according to the ACUITY scale as major or nonmajor bleeding. Kaplan-Meier and Cox proportional hazards analyses were performed. RESULTS Of 13,726 patients, 275 (2.0%) bled before angiography, including 52 (0.4%) with major bleeding. Forty-four (0.3%) experienced myocardial infarction. The median time from randomization to coronary angiography was 4.5 h (interquartile ratio [IQR]: 1.7 to 19.7 h) for patients who did not bleed while waiting for angiography and 27.9 h (IQR: 21.9 to 65.6 h) for patients who bled while waiting for angiography (p < 0.001). Bleeding events accrued linearly over time, reaching 10.4% at 96 h post-randomization. Independent predictors of bleeding before angiography included age (adjusted hazard ratio [HR]: 1.03 per year of age; 95% confidence interval [CI]: 1.01 to 1.04; p < 0.001), renal insufficiency (adjusted HR: 1.48; 95% CI: 1.07 to 2.04; p = 0.02), and use of multiple antithrombotic drugs (adjusted HR: 1.33; 95% CI: 1.14 to 1.56; p < 0.001). Bleeding before coronary angiography was associated with longer hospitalization (4.8 days [IQR: 3.0 to 8.9 days] vs. 3.0 days [IQR: 1.9 to 5.9 days]; p < 0.001). Patients who bled before angiography were more likely to die within 1 year than patients who did not bleed (8.5% vs. 4.1%; p < 0.001; adjusted HR: 1.89 (95% CI: 1.23 to 2.90; p = 0.004). CONCLUSIONS Upstream antithrombotic treatment of patients with non-ST-segment elevation acute coronary syndromes awaiting coronary angiography is associated with excess bleeding with mortality implications. Bleeding avoidance strategies before angiogram, including early angiography, may negate the need to prolong upstream antithrombotic treatment and improve the overall risk-benefit balance for these patients. (Acute Catheterization and Urgent Intervention Triage Strategy [ACUITY]; NCT00093158) (C) 2016 by the American College of Cardiology Foundation.

【 授权许可】

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