Prognosis is significantly worse with non-access site bleeding


A meta-analysis published in Circulation: Cardiovascular Interventions indicates that the prevalence of non-access site bleeding after percutaneous coronary intervention (PCI) is similar to that of access-site bleeding. However, it also shows that while both are associated with adverse outcomes, the former is associated with a significantly worse prognosis than is the latter.

Mamas A Mamas (Cardiovascular Research Group, University of Keele, UK) and others write that previous studies of bleeding after PCI—both access-site and non-access site—have reported conflicting data about the prevalence of such complications and their prognostic impact. They note: “To date, there has not been a systematic review or meta-analysis published studying the prevalence or prognostic impact of site-specific bleeding complications after PCI.” Therefore, the authors performed a meta-analysis of studies reviewing PCI outcomes to “systematically study the association of site-specific major bleeding complications after PCI and mortality and major adverse cardiac events (MACE) outcomes.”

Shing Kwok, the first author of the study, and others identified 25 studies (involving 240,0645 patients)—of which, 22 evaluated mortality as an outcome and nine evaluated MACE. They state that the prevalence of non-access site bleeding was similar to that of access-site bleeding (10.2% vs. 11.2%, respectively), but add that there may be a difference in prevalence in future because of the current drive towards using the transradial approach in both Europe and USA. “The development of the radial access site as the predominant access site choice in many countries, such as the UK, will serve to decrease the prevalence of access site-related complications, with non-access site bleeding complications representing the most common bleeding complications,” the authors comment.

In an analysis of five studies that evaluated the rate of morality associated with bleeding complications, non-access site bleeding was associated with a significantly higher rate of mortality than was access-site bleeding. Furthermore, Shing Kwok et al state: “The pooled risk of adverse outcomes (mortality, mortality and myocardial infarction, and MACE) was higher with non-access site bleeding compared with access-site bleeding (seven studies).”

The authors also looked at the prognosis associated with bleeding specific to the indication for PCI. They found that mortality was significantly higher in patients with ST-segment elevation myocardial (STEMI) who experienced non-access site bleeding than those with non-STEMI (NSTEMI) who experienced this type of bleeding. However, there were no significant differences in mortality rates between STEMI and NSTEMI patients who experienced access-site bleeding. 

Shing Kwok et al conclude: “Clinicians should minimise the risk of periprocedural major bleeding complications irrespective of access adopted during PCI through the use of bleeding avoidance strategies, such as the use of anticoagulants associated with reduced bleeding risk and use of proton pump inhibitors to reduce the risk of gastrointestinal bleeding complications in those patients at risk.” They add that “particular efforts” should made to reduce non-access site bleeding complications because “they have the greatest prognostic impact.”

Mamas told Cardiovascular News: “Major bleeding complications in the setting of PCI are associated with adverse outcomes. Our analysis suggests that the site of the bleed is also important. Clinicians should consider a personalised approach to patients, aimed at minimizing such complications, such as adoption of the radial approach to overcome access site related bleeds and careful consideration of pharmacology used, particularly in those patients at highest risk of bleeding complications such as the elderly, females, patients with renal failure and those undergoing PCI for acute coronary syndrome