Incidence and prognostic impact of post discharge bleeding post acute coronary syndrome within an outpatient setting: a systematic review

Abstract

ObjectiveThe primary objective was to determine the incidence of bleeding events post acute coronary syndrome (ACS) following hospital discharge. The secondary objective was to determine the prognostic impact of bleeding on mortality, major adverse cardiovascular events (MACE), myocardial re-infarction and rehospitalisation in the postdischarge setting.DesignA narrative systematic review.Data sourceMedline, Embase, Amed and Central (Cochrane) were searched up to August 2018.Study selectionFor the primary objective, randomised controlled trials (RCT) and observational studies reporting on the incidence of bleeding post hospital discharge were included. For the secondary objective, RCTs and observational studies that compared patients with bleeding versus those without bleeding post hospital discharge vis-à-vis mortality, MACE, myocardial re-infarction and rehospitalisation were included.Results53 studies (36 observational studies and 17 RCTs) with a combined cohort of 714 458 participants for the primary objectives and 187 317 for the secondary objectives were included. Follow-up ranged from 1 month to just over 4 years. The incidence of bleeding within 12 months post hospital discharge ranged from 0.20% to 37.5% in observational studies and between 0.96% and 39.4% in RCTs. The majority of bleeds occurred in the initial 3 months after hospital discharge with bruising the most commonly reported event. Major bleeding increased the risk of mortality by nearly threefold in two studies. One study showed an increased risk of MACE (HR 3.00,95% CI 2.75 to 3.27; p<0.0001) with bleeding and another study showed a non-significant association with rehospitalisation (HR 1.20,95% CI 0.95 to 1.52; p=0.13).ConclusionBleeding complications following ACS management are common and continue to occur in the long term after hospital discharge. These bleeding complications may increase the risk of mortality and MACE, but greater evidence is needed to assess their long-term effects.PROSPERO registration numberCRD42017062378.

Incidence and predictors of serious bleeding during long-term follow-up after acute coronary syndrome in a population-based cohort study

“…Previous studies have found that bleeding after ACS has an association with mortality similar to that of myocardial infarction 6 , and major bleeding correlates with a more prolonged mortality risk compared with ischemic events 7 . The incidence of post-discharge major bleeding within 1 year in patients with ACS has been reported as 1.3–5.6% in previous randomized trials (RCTs) and observational studies 8 – 10 , and up to one-third of patients discharged on dual antiplatelet therapy (DAPT) are reported to have had a bleeding complication within 12 months post-discharge 8 . Comparison of bleeding incidences among studies is difficult because of differences in the studied populations, follow-up times, in-hospital management, antithrombotic drugs used, and bleeding definitions 11 , 12 .…”

Bleeding After Hospital Discharge Following Acute Coronary Syndrome: Incidence, Types, Timing, and Predictors

“…After hospital discharge, patients with ACS often remain on dual antiplatelet therapy for up to a year, and aspirin indefinitely, so their risk of bleeding complications persists in the longer term. 7 Major in-hospital bleeding has been associated with sociodemographic characteristics, cardiovascular and noncardiovascular comorbidities, and pharmacological and procedural characteristics, [8][9][10] leading to the development of risk scoring algorithms that stratify patients into risk profiles for these bleeding events. [8][9][10] However, it is unclear whether these characteristics are also predictive of bleeding events after hospital discharge.…”

Prescription Rates for Antiplatelet Therapy (APT) in Coronary Artery Disease (CAD) – What Benchmark are We Aiming at in Continuing Medical Education (CME)?

“…e. We have no data to estimate to which extent complications emerging in the course of treatment might have influenced the results of this study, though e.g. bleeding complications might have occurred in a non-negligible proportion of patients [50][51][52].…”