Bleeding, Blood Transfusion, and Increased Mortality After Percutaneous Coronary Intervention

Abstract

Advances in percutaneous coronary intervention (PCI) during the past decade have led to more widespread use of these procedures in older and sicker patients. Refinement of periprocedural antithrombotic therapy has played a particularly important role in reducing ischemic complications to very low levels in routine practice. Although the use of more powerful antiplatelet agents has been associated with increased risk of bleeding (especially among the elderly and patients with serious comorbidities), such complications have traditionally been viewed as benign in nature. Recent studies, however, have identified major bleeding after PCI as an important predictor of increased mortality. Whether this relationship between bleeding and risk of death is cause-and-effect, or merely an association based on shared risk factors, remains unclear. In this review, we examine the basis for a possible causal link between post-PCI bleeding and subsequent mortality. Possible mechanisms underpinning such a link are discussed, including a potential adverse role for blood transfusion in this setting. A framework for further clinical evaluation of this issue is presented.

Antithrombotic Regimens for Patients Taking Oral Anticoagulation After Coronary Intervention: A Meta‐analysis of 16 Clinical Trials and 9185 Patients

“…It should be noted that similar results were found in other studies 14, 23. Moreover, several studies14, 31, 32 found that major bleeding was associated with increased risk of death, and bleeding was dangerous not only because of the hemorrhage itself but also because it forced the discontinuation of necessary anticoagulation, which might induce higher rates of thrombotic events. Disturbingly, bleeding events might be underestimated in studies, and the impact of bleeding could be even larger in real life than reported in these studies, because these studies were not specifically designed to detect bleeding events; this could explain why the rate of bleeding events reported in the WOEST trial12 was much higher than those in other studies 6, 15, 19, 20, 22.…”

Medicolegal implications of radial and femoral access for coronary angiography and intervention in 2016: Focus on retroperitoneal hemorrhage

“…Criteria for including legal cases were as follows: (1) cases that involved patients who underwent diagnostic catheterization and/or PCI for any indication (primary PCI, rescue PCI, and elective PCI) and (2) cases that reported retroperitoneal hemorrhage after the respective procedure was performed. Each case was thoroughly reviewed and information about the date the case was decided, the plaintiff, the defendant, the claim, and trial outcome were extracted.…”

“…Risks associated with TFA PCI include access site bleeding and other major vascular complications, with retroperitoneal hematoma being one of them, leading to higher risk of subsequent morbidity, mortality, and increase in length of stay and cost. [2] Retroperitoneal hemorrhage is an uncommon but potentially fatal complication of TFA PCI occurring in approximately 0.5-0.74% of transfemoral procedures. [3][4] Female gender, low body surface area, chronic renal failure, use of glycoprotein IIb/IIIa inhibitors, presentation with acute myocardial infarction (MI), and high placement of the sheath (above the inferior epigastric artery) have been reported as the most significant risk factors for retroperitoneal hemorrhage in various studies.…”

Bivalirudin: The relevance in today's interventional practice

“…However one problem that continues to haunt the cardiologists is the considerable incidence of bleeding complications following PCI. 1 We are now well aware that bleeding complications following PCI not only increased mortality and morbidity pre-discharge but also in the long term. The reasons for this could be several including the physical effects of blood loss, bleeding into critically important areas like brain, the need to discontinue antiplatelet therapy and the need for blood transfusions with its attendant adverse effects like reduced ability of blood to transfer oxygen, TRIM (transfusion related immune modulation) and so on.…”

“…The reasons for this could be several including the physical effects of blood loss, bleeding into critically important areas like brain, the need to discontinue antiplatelet therapy and the need for blood transfusions with its attendant adverse effects like reduced ability of blood to transfer oxygen, TRIM (transfusion related immune modulation) and so on. 1 Therefore any new modalities adopted to reduce bleeding complications are welcome like radial route for PCI. The recently published RIVAL study randomized patients of acute coronary syndromes to radial or femoral access during PCI.…”