Philippe Généreux (Cardiovascular Research Foundation, New York, USA) and others report in the Journal of the American College of Cardiology that data from ADAPT-DES (Assessment of dual antiplatelet therapy with drug-eluting stents) indicate that the risk of all-cause mortality that is associated with post-discharge bleeding after percutaneous coronary intervention (PCI) is 2.6-fold greater than the risk of all-cause mortality that is associated with post-discharge myocardial infarction.
The authors state that they performed the study because information for the impact and contribution of post-discharge bleeding to late mortality was “less certain” than it was for periprocedural bleeding and for post-discharge ischaemic events. Généreux et al report that, with the study, their aim was to “determine the incidence of post-discharge bleeding in patients who were in-hospital event-free after PCI with a drug-eluting stent, identify risk factors associated with the occurrence of post-discharge bleeding, and evaluate the time-dependent, multivariate adjusted effect of post-discharge bleeding on mortality within two years after the index procedure.”
Of the 8,577 patients in ADAPT-DES (an all-comers registry that assessed patients who underwent PCI with one or more drug-eluting stents), 533 (6.2%) had a total of 662 post-discharge bleeding events and the median time to first bleed was 300 days. Généreux et al comment that such events were “not uncommon” and that they “increased monotonically throughout the two-year post PCI follow-up period”—the rates of bleeding were 0.7%, 3.8%, and 8.8% at 30 days, one year, and two years respectively. A multivariate analysis indicated that older age, peripheral arterial disease, lower baseline haemoglobin levels, lower baseline P2Y12 reactivity units, and warfarin use at discharge were all significant independent predictors of post-discharge bleeding.
In a separate multivariate analysis, post-discharge bleeding was found to be the most significant predictor of two-year bleeding. This finding was irrespective of whether the patient underwent transfusion or not, with the authors stating: “this observation may be considered counterintuitive as patients receiving transfusions are often sicker, with multiple comorbidities and greater extent of bleeding.”
Furthermore, Génereux et al claim that the magnitude of the effect of post-discharge bleeding on subsequent mortality “was roughly 2.6-fold greater than the effect of post-discharge myocardial infarction” and claim that these findings “extend prior reports demonstrating the risk of bleeding is at least as prognostically important as myocardial infarction. The ongoing risk and strong association between mortality and post-discharge myocardial infarction may underlie the recent findings from randomised trials that short dual antiplatelet therapy (DAPT) duration may result in improved survival compared to prolonged DAPT, presumably by minimising bleeding-related complications.”
However, the authors note that some patients “at high risk for thrombotic events” may still benefit from a more potent prolonged duration of DAPT and, therefore, advise that the decision to prescribe a short or a longer course of DAPT “requires balancing the risk of future atherothrombotic events and bleeding risk.” Commenting that they found that some of the factors associated with the risk of bleeding were also associated with the risk of ischaemic events (such as older age), the authors state that the decision-making process “will remain challenging in some cases and must incorporate patient preferences”.
Study investigator Gregg Stone (Cardiovascular Research Foundation, New York, USA) says: “Both ischaemic and bleeding complications are important to consider in the individual patient when deciding on therapie—for example, the duration of DAPT. While some variables predict both bleeding and ischaemia, others predict one more than the other, allowing individualised treatment decisions to be made to optimise outcomes for each patient.”