Bleeding associated with procedures such as balloon angioplasty and stenting to treat acute coronary syndromes—conditions brought on by a sudden reduced blood flow to the heart—has been considered merely an unpleasant event with little effect on survival. Now, however, cardiologists in Europe argue that as patient outcomes have benefited from improvements in angioplasty and stenting, or percutaneous coronary intervention (PCI), bleeding in patients who have undergone PCI warrants more attention.
In a position paper published in the European Heart Journal, members of a European Society of Cardiology working group said that bleeding has emerged as a significant issue in managing patients with acute coronary syndromes and has important implications regarding prognosis, outcomes, and costs. Evidence has emerged, they noted, that patients with major bleeding episodes after PCI are at high risk of dying in the following months, although the causal mechanism remains unknown.
Risk factors for bleeding complications associated with PCI include old age, being female, having a lower body weight, and impaired kidney function. The treatment itself increases bleeding risk, the authors said, with about half of bleeding events occurring at the site at which access to the heart and major blood vessels is obtained via a puncture, usually in the femoral artery in the groin area or in the radial artery in the wrist. To minimize bleeding risk, they recommended using radial access over femoral access when inserting the PCI catheter, as well as adjusting the dose of anticoagulant agents, when possible, to take into account the patient’s weight, age, and kidney function.
Future study, the working group said, should seek to determine whether bleeding itself plays a role in subsequent mortality or if it is just a marker of increased risk related to worse baseline characteristics.