Post-Discharge Bleeding and Mortality Following Acute Coronary Syndromes With or Without PCI,Journal of the American College of Cardiology

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Post-Discharge Bleeding and Mortality Following Acute Coronary Syndromes With or Without PCI
Journal of the American College of Cardiology ( IF 21.7 ) Pub Date : 2020-07-01 , DOI: 10.1016/j.jacc.2020.05.031
Guillaume Marquis-Gravel ₁ , Frederik Dalgaard ₁ , Aaron D Jones ₁ , Yuliya Lokhnygina ₁ , Stefan K James ₂ , Robert A Harrington ₃ , Lars Wallentin ₂ , Philippe Gabriel Steg ₄ , Renato D Lopes ₅ , Robert F Storey ₆ , Shaun G Goodman ₇ , Kenneth W Mahaffey ₈ , Pierluigi Tricoci ₉ , Harvey D White ₁₀ , Paul W Armstrong ₁₁ , E Magnus Ohman ₅ , John H Alexander ₅ , Matthew T Roe ₅

Affiliation

Duke Clinical Research Institute, Durham, North Carolina.
Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
Department of Medicine, Stanford University, Stanford, California.
Université de Paris, Assistance Publique-Hôpitaux de Paris, and INSERM U1148, Paris, France; Royal Brompton Hospital, Imperial College, London, United Kingdom.
Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.
Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Stanford Center for Clinical Research, Department of Medicine, Stanford School of Medicine, Palo Alto, California.
CSL Behring, Durham, North Carolina.
Green Lane Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand.
Canadian VIGOUR Centre and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.

BACKGROUND 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. OBJECTIVES 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.

中文翻译：

急性冠脉综合征伴或不伴 PCI 后出院后出血和死亡率

背景出院后出血对未接受经皮冠状动脉介入治疗 (PCI) 治疗的急性冠脉综合征 (ACS) 患者的长期预后影响仍未得到探索。目的本研究的目的是根据指标策略（PCI 或不 PCI）评估出院后出血与 ACS 后死亡率之间的关联，并与出院后心肌梗死 (MI) 和后续死亡率之间的关联进行对比。方法在 4 项多中心随机试验（APPRAISE-2 [Apixaban 预防急性缺血性事件-2]、PLATO [血小板抑制和患者预后研究]、TRACER [凝血酶受体拮抗剂用于减少急性冠状动脉综合征的临床事件]）的统一数据集中], 和 TRILOGY ACS [Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes]），出院后非冠状动脉旁路移植相关的 GUSTO（全球使用打开闭塞冠状动脉的策略）中度、重度或生命之间的关联在时间更新的 Cox 比例风险分析中评估了威胁性出血（ACS 后 7 天的里程碑）和随后的全因死亡率。评估与指标治疗策略的相互作用。结果与出院后心肌梗死后的死亡风险形成对比。结果在 45,011 名参与者中，1,133 人出现出院后出血事件（每 100 患者年 2.6 人），2,149 人在随访期间死亡。死亡风险显着高于 <30 天（调整后的风险比：15.7；95% 置信区间：12.3 至 20。0) 和出血后 30 天至 12 个月（调整后的风险比：2.7；95% 置信区间：2.1 至 3.4），并且这种关联在接受或不接受 PCI 治疗的参与者的指数 ACS 中是一致的（交互作用 p = 0.240） . 在接受和未接受 PCI 治疗的参与者中，出院后出血与死亡率之间的时间相关性类似于 MI 与随后死亡率之间的关联（交互作用 p = 0.696）。结论 ACS 后出院后出血与接受或未接受 PCI 治疗的参与者随后全因死亡率的相似增加相关，并且与出院后 MI 具有相同的预后影响。这种关联在接受或不接受 PCI 治疗的参与者的指数 ACS 中是一致的（交互作用 p = 0.240）。在接受和未接受 PCI 治疗的参与者中，出院后出血与死亡率之间的时间相关性类似于 MI 与随后死亡率之间的关联（交互作用 p = 0.696）。结论 ACS 后出院后出血与接受或未接受 PCI 治疗的参与者随后全因死亡率的相似增加相关，并且与出院后 MI 具有相同的预后影响。这种关联在接受或不接受 PCI 治疗的参与者的指数 ACS 中是一致的（交互作用 p = 0.240）。在接受和未接受 PCI 治疗的参与者中，出院后出血与死亡率之间的时间相关性类似于 MI 与随后死亡率之间的关联（交互作用 p = 0.696）。结论 ACS 后出院后出血与接受或未接受 PCI 治疗的参与者随后全因死亡率的相似增加相关，并且与出院后 MI 具有相同的预后影响。

更新日期：2020-07-01

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