Author + information
- Received March 12, 2014
- Revision received January 4, 2015
- Accepted January 22, 2015
- Published online April 14, 2015.
- Dhruv S. Kazi, MD, MSc∗,†,‡∗ (, )http://twitter.com/kardiologykazi,
- Thomas K. Leong, MPH§,
- Tara I. Chang, MD, MS‖,
- Matthew D. Solomon, MD, PhD§,‖,
- Mark A. Hlatky, MD‖,¶ and
- Alan S. Go, MD‡,§,¶
- ∗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
- §Division of Research, Kaiser Permanente Northern California, Oakland, California
- ‖Department of Medicine, Stanford University, Stanford, California
- ¶Department of Health Research and Policy, Stanford University, Stanford, California
- ↵∗Reprint requests and correspondence:
Dr. Dhruv S. Kazi, Department of Medicine, and Department of Epidemiology and Biostatistics, University of California San Francisco, Division of Cardiology, San Francisco General Hospital, 1001 Potrero Avenue, Room 5G1, San Francisco, California 94110.
Background 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.
Objectives This study sought to examine, in a real-world cohort, the association between spontaneous major bleeding or MI after PCI and long-term mortality.
Methods 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.
Results 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.
Conclusions 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.
This study was funded in part by the American Heart Association (Grant Number 0875162N), Kaiser Permanente Northern California Division of Research, Stanford University, and the University of California-San Francisco. The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the manuscript. Dr. Go has received a research grant from Genentech. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 12, 2014.
- Revision received January 4, 2015.
- Accepted January 22, 2015.
- American College of Cardiology Foundation