Association of Ischemic and Bleeding Events With Mortality Among Patients in Sweden With Recent Acute Myocardial Infarction Receiving Antithrombotic Therapy

Abstract

IMPORTANCE Antithrombotic treatment after myocardial infarction (MI) should be individualized based on the patient's risk of ischemic and bleeding events. Uncertainty remains regarding the relative prognostic importance of the 2 types of events, and further study would be useful. OBJECTIVESTo compare the association of ischemic vs bleeding events with mortality in patients with a recent MI and assess whether the relative mortality risk for the 2 types of events has changed over the past 2 decades. DESIGN, SETTING, AND PARTICIPANTSA cohort study based on nationwide registers in Sweden, 2012-2017, was conducted. Data were analyzed between July 2021 and May 2022. Patients with MI who were discharged alive with antithrombotic therapy (antiplatelet therapy or oral anticoagulation) were included in the analysis. MAIN OUTCOMES AND MEASURESThe incidence of a first ischemic event (hospitalization for MI or ischemic stroke) or bleeding event (hospitalization with bleeding) up to 1 year after discharge and the mortality risk up to 1 year after each type of event were assessed. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHRs) for 1-year mortality after an ischemic and bleeding event vs no event, and after an ischemic vs bleeding event. Adjusted HRs for mortality after ischemic vs bleeding events were compared among patients discharged in 1997-2000, 2001-2011, and 2012-2017. RESULTSOf 86 736 patients discharged after MI in 2012 years; 57 287 [66.0%] men), 4039 individuals experienced a first ischemic event (5.7 per 100 person-years) and 3399 experienced a first bleeding event (4.8 per 100 person-years). The mortality rate was 46.2 per 100 person-years after an ischemic event and 27.1 per 100 person-years after a bleeding event.The aHR for 1-year mortality vs no event was 4.16 (95% CI, 3.91-4.43) after an ischemic event and 3.43 (95% CI, 3.17-3.71) after a bleeding event. When the 2 types of events were compared, the aHR was 1.27 (95% CI, 1.15-1.40) for an ischemic vs bleeding event. There was no statistically significant

Net clinical benefit of dual antiplatelet therapy in elderly patients with acute coronary syndrome: A systematic review and meta‐analysis

“…Fourth, the primary endpoint was the net clinical benefit outcome (MACEs and clinically relevant bleeding events), for which there is debate regarding its reliability in encompassing both ischemic and bleeding risks in a balanced manner 53 . However, several landmark trials, such as the POPular AGE trial, prudently used both major and minor bleeding events as components of the primary net clinical benefit outcome because minor or clinically irrelevant bleeding frequently leads to premature discontinuation of DAPT and puts patients at risk of thrombotic events and significantly increased mortality 14,54 . Following previous well‐designed cornerstone trials, we defined the net clinical benefit outcome.…”

“…53 However, several landmark trials, such as the POPular AGE trial, prudently used both major and minor bleeding events as components of the primary net clinical benefit outcome because minor or clinically irrelevant bleeding frequently leads to premature discontinuation of DAPT and puts patients at risk of thrombotic events and significantly increased mortality. 14,54 Following previous well-designed cornerstone trials, we defined the net clinical benefit outcome. Fifth, prasugrel and ticagrelor were combined in the potent P2Y 12 inhibitor group, as it was impossible to separate them for this meta-analysis.…”

The Association of CHADS-P2A2RC Risk Score With Clinical Outcomes in Patients Taking P2Y12 Inhibitor Monotherapy After 3 Months of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention

“… 5) In some cases, a disproportionate increase was reported in ischemic risk compared with bleeding risk in patients with multiple risk factors. 6) Aspirin cessation after 1–3 months of DAPT and continuation with P2Y12 inhibitor monotherapy has been shown to favorably affect the balance between bleeding and ischemic risk among unselected patients undergoing PCI. 7) 8) However, concerns remain that early aspirin withdrawal may be associated with potential harm in high ischemic risk patients.…”