Periprocedural bleeding remains one of the most common adverse events after percutaneous coronary intervention (PCI) and is associated with increased mortality. Although strategies to minimize PCI bleeding have been identified, these strategies are infrequently applied to patients at highest bleeding risk. Using a pre-post study design, Spertus et al. evaluated the impact of assessing individual patient bleeding risk from validated models and providing this bleeding risk estimate in personalized informed consent documents for PCI. The intent of the intervention was to increase the procedural team’s awareness of patients at low, moderate, and risk for PCI related bleeding and thereby influence the use of bleeding avoidance strategies (i.e. bivalirudin, radial access, and vascular closure devices) and reduce periprocedural bleeding events. The study included 7408 pre-intervention PCI and 3529 post-intervention PCI from 9 hospitals in the United States. Following implementation of the intervention, use of bleeding avoidance strategies increased (odds ratio for use of bleeding avoidance strategies: 1.81, 95% confidence interval 1.44-2.27), especially among higher risk individuals (OR 2.03, 95% CI 1.58-2.61). Furthermore, bleeding rates were lower following implementation of the intervention (1.0 v. 1.7%, OR 0.62, 95% CI 0.44 to 0.87 after adjustment for contemporary trends). Following the intervention, significant variation remained both between and within hospitals with regards to use of bleeding avoidance strategies.
Conclusion: Providing clinicians with individual patient bleeding risks immediately prior to PCI was associated with increased and targeted use of bleeding avoidance strategies and lower risk-adjusted bleeding rates. However, significant variability in the approach to bleeding avoidance persisted after implementation of this tool.
Summarized by Javier A. Valle and Steven M. Bradley
- Spertus JA, Decker C, Gialde E, et al. Precision medicine to improve use of bleeding avoidance strategies and reduce bleeding in patients undergoing percutaneous coronary intervention: prospective cohort study before and after implementation of personalized bleeding risks. BMJ. 2015 Mar 24;350:h1302.