Coronary artery disease
Bleeding-Avoidance Strategies and Outcomes in Patients ≥80 Years of Age With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention (from the NCDR CathPCI Registry)

https://doi.org/10.1016/j.amjcard.2012.02.039Get rights and content

The purpose of our study was to evaluate the use of bleeding-avoidance strategies (BAS) and risk-adjusted bleeding over time in patients ≥80 years of age undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction. We analyzed data from the CathPCI Registry from July 1, 2006 through June 30, 2009. Patients were included if they were ≥80 years old, presented with ST-segment elevation myocardial infarction, and underwent primary PCI. We evaluated trends in use of BAS (direct thrombin inhibitors, vascular closure devices, and radial access) and risk-adjusted bleeding over time. Of 10,469 patients ≥80 years old undergoing primary PCI, 1,002, (9.6%) developed a bleeding complication. Use of direct thrombin inhibitors and vascular closure devices increased over time (12.8% to 24.9% and 29.2% to 32.7%, p <0.01 and <0.05 for trends, respectively). Radial access was extremely uncommon (<1%) and did not change over the course of the study. In multivariable analyses, use of BAS was associated with lower bleeding. However, over the course of the study period, overall risk-adjusted bleeding did not decrease significantly (9.9% to 9.4%, p = 0.14 for trend). In conclusion, patients ≥80 years old undergoing primary PCI are at high risk of bleeding, and despite significant increases in use of BAS, the overall rate of bleeding complications remains high.

Section snippets

Methods

The NCDR CathPCI Registry is a large voluntary quality improvement program cosponsored by the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions.7 The registry includes clinical and in-hospital outcome data on patients undergoing cardiac catheterization and PCI procedures including baseline clinical and sociodemographic characteristics, adjunctive therapies, complications, and mortality. Definitions for data elements within the registry are available

Results

From an initial sample of 218,935 cases with primary PCI for STEMI from July 2006 through June 2009, the following were excluded: 1,050 for not being the first PCI, 16,175 for PCI not coded as emergency or salvage, 54,511 for transfer from another hospital, 4,083 with door-to-balloon time <15 minutes or >6 hours, and 39,540 for PCI performed at hospitals that did not participate continuously in the CathPCI Registry from 2006 through 2009. This left a final sample of 103,576 procedures for

Discussion

In a large cohort of patients undergoing primary PCI for STEMI, those ≥80 years of age had a nearly twofold increased risk of in-hospital bleeding compared to patients <80. In multivariable analyses, BAS were associated with a lower risk of bleeding, but <1/2 of population received even 1 BAS. Furthermore, although there were modest increases in use of BAS in patients ≥80 years old over the study period, observed risk-adjusted bleeding rates and risk-adjusted mortality did not significantly

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    The project described was supported by Award U01HL105270 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland. Dr. Dodson is supported by Training Grant T32 AG019134 in Geriatric Clinical Epidemiology from the National Institutes of Health/National Institute on Aging, Bethesda, Maryland. Dr. Chaudhry is supported by Beeson Career Development Award K23 AG030986 from the National Institutes of Health/National Institute on Aging, Bethesda, Maryland. The CathPCI Registry is an initiative of the American College of Cardiology Foundation and the Society for Cardiovascular Angiography and Interventions.

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