title: The association of in-hospital major bleeding with short-, intermediate-, and long-term mortality among older patients with non-ST-segment elevation myocardial infarction.
abstract: OBJECTIVE
  Bleeding complications have been associated with short-term mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). Their association with long-term outcomes is less clear. This study examines mortality associated with in-hospital bleeding during NSTEMI over time intervals starting from hospital discharge and extending past 3 years.
  
  
  RESULTS
  We studied 32 895 NSTEMI patients aged ≥65 years, using patient-level data from the CRUSADE registry linked with Medicare claims data. We assessed the association of in-hospital major bleeding with short (30 days), intermediate (1 year), and long-term (3 years) mortality among hospital survivors overall, as well as in those patients treated with or without a percutaneous coronary intervention (PCI). We calculated adjusted hazard ratios (HRs) for mortality for bleeders vs. non-bleeders over time intervals from: (i) discharge to 30 days; (ii) 31 days to 1 year; (iii) 1 year to 3 years; and (iv) beyond 3 years. Overall, 11.9% (n = 3902) had an in-hospital major bleeding event. Cumulative mortality was higher in those who had a major bleed vs. those without at 30 days, 1 year, and 3 years. Even after adjustment, major bleeding continued to be significantly associated with higher mortality over time in the overall population: (i) discharge to 30 days [adjusted HR 1.33; 95% confidence interval (CI) 1.18-1.51]; (ii) 31 days to 1 year (1.19; 95% CI 1.10-1.29); (iii) 1 year to 3 years (1.09; 95% CI 1.01-1.18), and (iv) attenuating beyond 3 years (1.14; 95% CI 0.99-1.31). In-hospital bleeding among patients treated with PCI continued to be significantly associated with higher adjusted mortality even beyond 3 years (1.25; 95% CI 1.01-1.54).
  
  
  CONCLUSIONS
  In-hospital major bleeding is associated with short-, intermediate-, and long-term mortality among older patients hospitalized for NSTEMI-this association is strongest within the first 30 days, but remains significant long term, particularly among PCI-treated patients. Despite a probable early hazard related to bleeding, the longer duration of risk in patients who bleed casts doubt on its causal relationship with long-term mortality. Rather, major bleeding likely identifies patients with an underlying risk for mortality.
authors.affiliation: Duke Clinical Research Institute, Box 3850, 2400 Pratt Street, Room 0311, Terrace Level, Durham, NC 27705, USA. renato.lopes@duke.edu
authors.forename: Renato D
authors.initials: RD
authors.lastname: Lopes
authors.forename: Sumeet
authors.initials: S
authors.lastname: Subherwal
authors.forename: Dajuanicia N
authors.initials: DN
authors.lastname: Holmes
authors.forename: Laine
authors.initials: L
authors.lastname: Thomas
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
authors.forename: Sunil V
authors.initials: SV
authors.lastname: Rao
authors.forename: Erik
authors.initials: E
authors.lastname: Magnus Ohman
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
authors.forename: Karen P
authors.initials: KP
authors.lastname: Alexander
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000009:adverse effects; D005260:Female; D006470:Hemorrhage / Q000401:mortality*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality* / Q000628:therapy; D062645:Percutaneous Coronary Intervention / Q000401:mortality*; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects; D012189:Retrospective Studies
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors